Provider Demographics
NPI:1316987605
Name:KIM, SEONG IL (MD)
Entity type:Individual
Prefix:
First Name:SEONG
Middle Name:IL
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 1:541 W COLORADO ST STE 205
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-3640
Mailing Address - Country:US
Mailing Address - Phone:323-254-0046
Mailing Address - Fax:323-488-9782
Practice Address - Street 1:1245 WILSHIRE BLVD STE 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-977-1214
Practice Address - Fax:213-482-8868
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC139331207RH0003X, 207RH0003X
OH35058531K207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0856300Medicaid
F24023Medicare UPIN
OHH133140Medicare PIN
OH0712261Medicare PIN
OH0856300Medicaid
OH0712261Medicare PIN
OH000000118394OtherANTHEM
830000423OtherTRAVELERS MEDICARE
OHH133140Medicare PIN
OH0856300Medicaid