Healthcare Provider Details

I. General information

NPI: 1316972235
Provider Name (Legal Business Name): KRISTINA I BOSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UCLA MEDICAL PLZ STE 690
LOS ANGELES CA
90024-7000
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-2235
  • Fax: 310-825-2092
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA52816
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: