Healthcare Provider Details

I. General information

NPI: 1063568293
Provider Name (Legal Business Name): KIM ESCUDERO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SIERRA PARK RD
MAMMOTH LAKES CA
93546-0660
US

IV. Provider business mailing address

PO BOX 660 85 SIERRA PARK RD
MAMMOTH LAKES CA
93546-0660
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-4000
  • Fax: 760-924-4091
Mailing address:
  • Phone: 760-924-4000
  • Fax: 760-924-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA61421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: