Provider Demographics
NPI:1427169531
Name:LANGEVIN, KATHY KIM (MD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:KIM
Last Name:LANGEVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHY
Other - Middle Name:HEE-WON
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:12301 WILSHIRE BLVD 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1000
Mailing Address - Country:US
Mailing Address - Phone:310-207-8900
Mailing Address - Fax:310-207-8912
Practice Address - Street 1:12301 WILSHIRE BLVD 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1000
Practice Address - Country:US
Practice Address - Phone:301-207-8900
Practice Address - Fax:310-207-8912
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41753207N00000X
IA36174207N00000X
CAA85857207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A858570Medicaid
CAAO062ZMedicare PIN
CAAO062YMedicare PIN