Provider Demographics
NPI:1972589299
Name:KALTENBORN, KONRAD C (MD)
Entity type:Individual
Prefix:
First Name:KONRAD
Middle Name:C
Last Name:KALTENBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 PROVIDENCE DR
Mailing Address - Street 2:#523
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4608
Mailing Address - Country:US
Mailing Address - Phone:907-222-1714
Mailing Address - Fax:907-222-1724
Practice Address - Street 1:3260 PROVIDENCE DR
Practice Address - Street 2:#523
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4608
Practice Address - Country:US
Practice Address - Phone:907-222-1714
Practice Address - Fax:907-222-1724
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3556207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0193230OtherWA DEPT L&I
AKMD10041Medicaid
AKMD10044Medicaid
AKK0000BLCCPMedicare PIN
AK0193230OtherWA DEPT L&I
AKK150054Medicare ID - Type UnspecifiedNORIDIAN MEDICARE