Healthcare Provider Details

I. General information

NPI: 1346432069
Provider Name (Legal Business Name): FAITH PAULINE CHISUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

IV. Provider business mailing address

949 PALM AVE
IMPERIAL BEACH CA
91932-1503
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax: 619-429-3823
Mailing address:
  • Phone: 619-429-3733
  • Fax: 619-429-3823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA98040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: