Healthcare Provider Details

I. General information

NPI: 1083637755
Provider Name (Legal Business Name): KIM MARIE THOMAS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13173 BLACK MOUNTAIN RD STE 3
SAN DIEGO CA
92129-2687
US

IV. Provider business mailing address

13173 BLACK MOUNTAIN RD STE 3
SAN DIEGO CA
92129-2687
US

V. Phone/Fax

Practice location:
  • Phone: 858-484-2800
  • Fax: 858-484-2810
Mailing address:
  • Phone: 858-484-2800
  • Fax: 858-484-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A7074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: