Healthcare Provider Details

I. General information

NPI: 1508395534
Provider Name (Legal Business Name): JAIME KYUNG STULL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2017
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 L ST
CHULA VISTA CA
91911-1066
US

IV. Provider business mailing address

34800 BOB WILSON DR BUILDING 3, FLOOR 3, INTERNAL MEDICINE
SAN DIEGO CA
92134-1003
US

V. Phone/Fax

Practice location:
  • Phone: 619-271-7100
  • Fax:
Mailing address:
  • Phone: 619-881-9169
  • Fax: 619-532-9134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA158613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: