Provider Demographics
NPI:1285725051
Name:KIM, KWANG SOOK (MD)
Entity type:Individual
Prefix:
First Name:KWANG
Middle Name:SOOK
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9636 GARDEN GROVE BLVD # 16
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1530
Mailing Address - Country:US
Mailing Address - Phone:714-290-1657
Mailing Address - Fax:562-404-4323
Practice Address - Street 1:9636 GARDEN GROVE BLVD # 16
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1530
Practice Address - Country:US
Practice Address - Phone:714-290-1657
Practice Address - Fax:562-404-4323
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37552208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A375520Medicaid
CA00A375520Medicaid