Provider Demographics
NPI:1225564818
Name:KIM, CHARLES CHOL BAE (MD)
Entity type:Individual
Prefix:
First Name:CHARLES CHOL BAE
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 1:1200 W MOHAVE RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-6349
Mailing Address - Country:US
Mailing Address - Phone:928-669-7380
Mailing Address - Fax:
Practice Address - Street 1:14642 NEWPORT AVE STE 105
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:714-831-1112
Practice Address - Fax:714-486-2309
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54481207Q00000X
CAC-129160207QG0300X
CAC129160207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty