Provider Demographics
NPI:1215061577
Name:KIM, YONG J (MD)
Entity type:Individual
Prefix:MR
First Name:YONG
Middle Name:J
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 1:3055 WILSHIRE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1119
Mailing Address - Country:US
Mailing Address - Phone:213-484-1000
Mailing Address - Fax:213-484-2662
Practice Address - Street 1:3055 WILSHIRE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1119
Practice Address - Country:US
Practice Address - Phone:213-484-1000
Practice Address - Fax:213-484-2662
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22626174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA22626AMedicare ID - Type Unspecified
CAA23182Medicare UPIN