Provider Demographics
NPI:1063568293
Name:ESCUDERO, KIM (MD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:ESCUDERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:85 SIERRA PARK RD
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-924-4000
Mailing Address - Fax:760-924-4091
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-0660
Practice Address - Country:US
Practice Address - Phone:760-924-4000
Practice Address - Fax:760-924-4091
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61421208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics