Provider Demographics
NPI:1609834803
Name:KAUSHANSKY, KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:KAUSHANSKY
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 1:336 PINE NEEDLES DR
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3330
Mailing Address - Country:US
Mailing Address - Phone:858-793-1479
Mailing Address - Fax:619-543-3931
Practice Address - Street 1:402 DICKINSON ST
Practice Address - Street 2:MAIL CODE 8811 - SUITE 380
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6902
Practice Address - Country:US
Practice Address - Phone:619-543-6170
Practice Address - Fax:619-543-3931
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86586207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G865860Medicaid
CAWG86586AMedicare ID - Type Unspecified
CA00G865860Medicaid