Provider Demographics
NPI:1972697605
Name:PERCY, KRISTINE SUE (MD,)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:SUE
Last Name:PERCY
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 1:539 SOUTH BREA BLVD
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821
Mailing Address - Country:US
Mailing Address - Phone:714-671-2936
Mailing Address - Fax:714-671-2938
Practice Address - Street 1:539 SOUTH BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821
Practice Address - Country:US
Practice Address - Phone:714-671-2936
Practice Address - Fax:714-671-2938
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77388207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1306971262OtherGROUP NPI
CAGR0101050Medicaid
ZZZ092862OtherBLUE SHIELD
ZZZ092862OtherBLUE SHIELD
CA1306971262OtherGROUP NPI
CAWG77388EMedicare PIN