Healthcare Provider Details

I. General information

NPI: 1003100579
Provider Name (Legal Business Name): JAMES DAVID KILLEEN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE KAISER PERMANENTE FONTANA - PEDIATRICS
FONTANA CA
92335-6720
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-6960
  • Fax:
Mailing address:
  • Phone: 877-608-0044
  • Fax: 877-514-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA126081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: