Provider Demographics
NPI:1992962013
Name:KURT R WHARTON MD, INC.
Entity type:Organization
Organization Name:KURT R WHARTON MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCGETTIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-962-0002
Mailing Address - Street 1:970 DEWING AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4291
Mailing Address - Country:US
Mailing Address - Phone:925-962-0002
Mailing Address - Fax:925-962-0003
Practice Address - Street 1:970 DEWING AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4291
Practice Address - Country:US
Practice Address - Phone:925-962-0002
Practice Address - Fax:925-962-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57090174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G570900Medicaid
CAE25129Medicare UPIN