Healthcare Provider Details

I. General information

NPI: 1346510096
Provider Name (Legal Business Name): GRACE TING KAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 BALDWIN AVE
SAN MATEO CA
94401-3915
US

IV. Provider business mailing address

2974 ARGUELLO DR
BURLINGAME CA
94010-5802
US

V. Phone/Fax

Practice location:
  • Phone: 650-579-6581
  • Fax:
Mailing address:
  • Phone: 650-652-9697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG87698
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: