Provider Demographics
NPI:1144327248
Name:KU, CHRISTINE W (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:W
Last Name:KU
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 1:3925 OLD REDWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1719
Mailing Address - Country:US
Mailing Address - Phone:707-566-5452
Mailing Address - Fax:
Practice Address - Street 1:3925 OLD REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1719
Practice Address - Country:US
Practice Address - Phone:707-566-5452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51152174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C511520Medicaid
CA00C511520Medicare ID - Type Unspecified
CA00C511520Medicaid