Provider Demographics
NPI:1063532778
Name:KIM, WARREN TACKHOON (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:TACKHOON
Last Name:KIM
Suffix:
Gender:M
Credentials:MD, PHD
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:415-600-0528
Mailing Address - Fax:415-369-1207
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:415-600-0528
Practice Address - Fax:415-369-1207
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA919212085N0700X, 2085R0202X, 2085R0204X
CA8932192085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1063532778Medicaid
CAA91921OtherSTATE MEDICAL LICENSE
CAP01266715OtherRAILROAD MEDICARE
CACA122076Medicare PIN
CABU151SMedicare PIN
CACA122075Medicare PIN
CABU515TMedicare PIN
CABU515UMedicare PIN