Provider Demographics
NPI:1366493629
Name:COCKERHAM, KIMBERLY P (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:P
Last Name:COCKERHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:PEELE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23052 ALICIA PKWY STE 619
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1643
Mailing Address - Country:US
Mailing Address - Phone:650-804-9270
Mailing Address - Fax:
Practice Address - Street 1:3590 CAMINO DEL RIO N STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1707
Practice Address - Country:US
Practice Address - Phone:619-810-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86885207W00000X, 207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G868850Medicaid
CA00G868850Medicare PIN
CACT919XMedicare PIN
CACT919YMedicare PIN
CACT919WMedicare PIN
CAF87784Medicare UPIN
CACT919VMedicare PIN
CACT919UMedicare PIN
CACT919TMedicare PIN