Healthcare Provider Details

I. General information

NPI: 1356607121
Provider Name (Legal Business Name): CHRISTOPHER J KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BON AIR RD
GREENBRAE CA
94904-1702
US

IV. Provider business mailing address

1615 HILL ROAD STE B MARIN MEDICAL LABORATORIES
NOVATO CA
94947-4338
US

V. Phone/Fax

Practice location:
  • Phone: 415-925-7174
  • Fax: 415-461-7228
Mailing address:
  • Phone: 415-898-7649
  • Fax: 415-898-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA131506
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: