Provider Demographics
NPI:1316990567
Name:KIM, BRIAN S (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
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:DEPT LA 21562
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1562
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-0473
Practice Address - Street 1:ONE HOAG DRIVE
Practice Address - Street 2:CANCER CENTER
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4162
Practice Address - Country:US
Practice Address - Phone:949-764-5528
Practice Address - Fax:949-764-8106
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA775662085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A775660Medicaid
CA00A775660OtherBLUE SHIELD OF CA
CA00A775660Medicaid
CAI30917Medicare UPIN
CAWA7566AMedicare PIN