Provider Demographics
NPI:1639321839
Name:YIMAM, KIDIST KIDANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIDIST
Middle Name:KIDANE
Last Name:YIMAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:415-600-1594
Mailing Address - Fax:415-922-1594
Practice Address - Street 1:1100 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-1020
Practice Address - Fax:415-922-1594
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103412204F00000X, 207R00000X, 207RG0100X, 207RI0008X
CA906368207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA103412OtherSTATE MEDICAL LICENSE