Healthcare Provider Details

I. General information

NPI: 1881897494
Provider Name (Legal Business Name): TIMOTHY S KRISTEDJA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2007
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 560W
SANTA MONICA CA
90404-2182
US

IV. Provider business mailing address

2477 WALNUT AVE
VENICE CA
90291-5018
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-5654
  • Fax: 310-453-6885
Mailing address:
  • Phone: 626-367-2824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA108522
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: