Provider Demographics
NPI:1164627501
Name:STIDHAM, KALLE MARC (DO)
Entity Type:Individual
Prefix:DR
First Name:KALLE
Middle Name:MARC
Last Name:STIDHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:500 ARGUELLO ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1566
Mailing Address - Country:US
Mailing Address - Phone:650-851-4900
Mailing Address - Fax:650-995-1202
Practice Address - Street 1:550 S WINCHESTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2544
Practice Address - Country:US
Practice Address - Phone:650-851-4900
Practice Address - Fax:408-556-8415
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2016-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A10063207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACM694ZMedicare PIN
CACM694YMedicare PIN