Provider Demographics
NPI:1306877006
Name:KIM, STEVEN PARK (DPM)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:PARK
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 MENDOCINO AVE
Mailing Address - Street 2:200
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3634
Mailing Address - Country:US
Mailing Address - Phone:707-575-6049
Mailing Address - Fax:707-545-0575
Practice Address - Street 1:4761 HOEN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7862
Practice Address - Country:US
Practice Address - Phone:707-545-0570
Practice Address - Fax:707-545-0575
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4506213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01011615OtherRAILROAD MEDICARE
CA000E45060Medicaid
CAP00336765Medicare PIN
CAFM916ZMedicare PIN
CAU98086Medicare UPIN
CA5234710001Medicare NSC
CA000E45060Medicare PIN