Provider Demographics
NPI:1871514687
Name:MAXWELL, KENNETH L II (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:MAXWELL
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 LONGLEAF DR,
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758
Mailing Address - Country:US
Mailing Address - Phone:951-737-2683
Mailing Address - Fax:951-273-2318
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:STE 3150
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX79720Medicaid
H88193Medicare UPIN
CA00AX79720Medicaid