Provider Demographics
NPI:1770044505
Name:BIALOS, AUDREY KYRA TEMPELSMAN (DO)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:KYRA TEMPELSMAN
Last Name:BIALOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-2674
Mailing Address - Country:US
Mailing Address - Phone:510-898-4200
Mailing Address - Fax:
Practice Address - Street 1:2621 10TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2674
Practice Address - Country:US
Practice Address - Phone:510-898-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA19592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program