Provider Demographics
NPI:1639124803
Name:KILCHESKI, THOMAS S (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:KILCHESKI
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 1:7777 ALVARADO RD #108
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-460-2770
Mailing Address - Fax:619-460-2774
Practice Address - Street 1:8881 FLETCHER PARKWAY #102
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-461-1830
Practice Address - Fax:619-797-1484
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG449542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G449540OtherBLUE SHIELD PIN
CA00G449540Medicaid
WG44954AMedicare PIN
A49822Medicare UPIN
CAWG44954DMedicare PIN
CA300015049Medicare PIN
CA00G449540Medicaid
CAWG44954AMedicare PIN