Provider Demographics
NPI:1831489855
Name:SHUMILAK, KAILI JI (DO)
Entity Type:Individual
Prefix:MS
First Name:KAILI
Middle Name:JI
Last Name:SHUMILAK
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 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-906-4623
Mailing Address - Fax:619-906-4564
Practice Address - Street 1:18406 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4107
Practice Address - Country:US
Practice Address - Phone:818-993-4054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty