Provider Demographics
NPI:1124390679
Name:MISSION PEDIATRIC MED CL
Entity type:Organization
Organization Name:MISSION PEDIATRIC MED CL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DUKE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-6040
Mailing Address - Street 1:27800 MEDICAL CENTER RD
Mailing Address - Street 2:STE 116
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6410
Mailing Address - Country:US
Mailing Address - Phone:949-364-6040
Mailing Address - Fax:949-364-0502
Practice Address - Street 1:27800 MEDICAL CENTER RD
Practice Address - Street 2:STE 116
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6410
Practice Address - Country:US
Practice Address - Phone:949-364-6040
Practice Address - Fax:949-364-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780690636OtherNPI
CAWA24150AMedicare PIN