Provider Demographics
NPI:1639120090
Name:VAN LOM, KRIS J (MD)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:J
Last Name:VAN LOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-626-7275
Mailing Address - Fax:858-626-4085
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-626-7275
Practice Address - Fax:858-626-4085
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG566412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G566410Medicaid
CA00G566410OtherBLUE SHIELD PIN
CAWG56641JMedicare PIN
CA00G566410Medicaid
CAWG56641KMedicare PIN
CAWG56641GMedicare PIN
CAWG56641IMedicare PIN