Provider Demographics
NPI:1043748692
Name:KIZER, KENNETH WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:KIZER
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 1:3740 CLOVER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-1504
Mailing Address - Country:US
Mailing Address - Phone:916-734-4754
Mailing Address - Fax:
Practice Address - Street 1:3740 CLOVER VALLEY RD
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-1504
Practice Address - Country:US
Practice Address - Phone:916-624-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41907207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANONEOtherNONE