Provider Demographics
NPI:1568472389
Name:DRAKE, KEVIN K (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:K
Last Name:DRAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2428 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE LL
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2045
Mailing Address - Country:US
Mailing Address - Phone:310-315-1000
Mailing Address - Fax:310-829-0348
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:SUITE LL
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:310-829-0348
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG35245174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02625Medicare UPIN