Healthcare Provider Details

I. General information

NPI: 1396002390
Provider Name (Legal Business Name): KIMBERLY REIGEL WADA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY ANNE REIGEL M.D.

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E COLUMBIA ST SUITE 210
LONG BEACH CA
90806-1620
US

IV. Provider business mailing address

455 E COLUMBIA ST SUITE 210
LONG BEACH CA
90806-1620
US

V. Phone/Fax

Practice location:
  • Phone: 844-822-4646
  • Fax:
Mailing address:
  • Phone: 844-822-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA127132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: