Provider Demographics
NPI:1154434728
Name:KIM, ILKYOON (MD)
Entity type:Individual
Prefix:DR
First Name:ILKYOON
Middle Name:
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:PO BOX 5326
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-5326
Mailing Address - Country:US
Mailing Address - Phone:707-994-4210
Mailing Address - Fax:707-994-0839
Practice Address - Street 1:15666 18TH AVENUE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-4210
Practice Address - Fax:707-994-0839
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34081207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34081OtherLICENSE NUMBER
CA00A340810Medicaid
68-0068216OtherBLUE CROSS
CA00A340812OtherBLUE SHIELD
CA00A340811OtherBLUE SHIELD
CA00A340811Medicaid
CA00A340811Medicaid
CAA34081OtherLICENSE NUMBER
CA00A340810Medicaid