Provider Demographics
NPI:1407410533
Name:KIM, KRISTEN (MD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 HIGH BLUFF DR STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2053
Mailing Address - Country:US
Mailing Address - Phone:858-215-2820
Mailing Address - Fax:858-216-8013
Practice Address - Street 1:12625 HIGH BLUFF DR STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2053
Practice Address - Country:US
Practice Address - Phone:858-215-2820
Practice Address - Fax:858-216-8013
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1781942084P0800X
CAA1781942084P0804X, 2084P0804X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program