Provider Demographics
NPI:1982707956
Name:HONSIK, KENNETH A
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:HONSIK
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 1:2999 REGENT ST
Mailing Address - Street 2:STE 225
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2190
Mailing Address - Country:US
Mailing Address - Phone:510-704-7760
Mailing Address - Fax:510-704-7765
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:STE 225
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2190
Practice Address - Country:US
Practice Address - Phone:510-704-7760
Practice Address - Fax:510-704-7765
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA71509OtherLIC
CAA71509OtherLIC
CACA131539Medicare PIN