Provider Demographics
NPI:1073743621
Name:KIM, MARK SUNG-KYOUNG (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:SUNG-KYOUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11539 HAWTHORNE BLVD
Mailing Address - Street 2:6E
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2381
Mailing Address - Country:US
Mailing Address - Phone:310-675-5370
Mailing Address - Fax:
Practice Address - Street 1:11539 HAWTHORNE BLVD
Practice Address - Street 2:6E
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2381
Practice Address - Country:US
Practice Address - Phone:310-675-5370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAU29035993617390200000X
CAA120844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program