Healthcare Provider Details

I. General information

NPI: 1164627501
Provider Name (Legal Business Name): KALLE MARC STIDHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2007
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S WINCHESTER BLVD SUITE 100
SAN JOSE CA
95128-2544
US

IV. Provider business mailing address

500 ARGUELLO ST SUITE 100
REDWOOD CITY CA
94063-1566
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-4900
  • Fax: 408-556-8415
Mailing address:
  • Phone: 650-851-4900
  • Fax: 650-995-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A10063
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: