Provider Demographics
NPI:1376568808
Name:FORDHAM, KIMBERLY JO (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:FORDHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JO
Other - Last Name:MELDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1519
Mailing Address - Street 2:21337 BUSH STREET
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95461-1519
Mailing Address - Country:US
Mailing Address - Phone:707-987-3311
Mailing Address - Fax:707-987-2455
Practice Address - Street 1:21337 BUSH STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95461-1519
Practice Address - Country:US
Practice Address - Phone:707-987-3311
Practice Address - Fax:707-987-2455
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH78070Medicare UPIN