Provider Demographics
NPI:1962582288
Name:KAROTKIN, KENNETH MARK
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:KAROTKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROME DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-3226
Mailing Address - Country:US
Mailing Address - Phone:323-226-0322
Mailing Address - Fax:323-227-4800
Practice Address - Street 1:900 ROME DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-3226
Practice Address - Country:US
Practice Address - Phone:323-226-0322
Practice Address - Fax:323-227-4800
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44469415103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP5503EMedicare PIN