Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | G62030 | CA |
N | 111NI0900X | Internist | G62030 | CA |
Y | 207RA0401X | Internist - Addiction Medicine | G62030 | CA |
NPI | 1962511162 |
---|---|
Provider Name | Kristopher Dane Howalt |
First Address | Canoga Park, CA 91303-1531 |
Second Address | Canoga Park, CA 91303-1531 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 19/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
D66581 | (02) |