Provider Demographics
NPI:1750570123
Name:CHESEBRO, KEVIN RAY (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RAY
Last Name:CHESEBRO
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 1:9675 SWAN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6608
Mailing Address - Country:US
Mailing Address - Phone:916-797-1963
Mailing Address - Fax:916-797-1963
Practice Address - Street 1:9675 SWAN LAKE DR
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6608
Practice Address - Country:US
Practice Address - Phone:916-797-1963
Practice Address - Fax:916-797-1963
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85433208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery