Provider Demographics
NPI:1457391773
Name:KIM, KYUNG NAM (MD)
Entity type:Individual
Prefix:
First Name:KYUNG NAM
Middle Name:
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 1:740 OAK AVENUE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6814
Mailing Address - Country:US
Mailing Address - Phone:916-250-0377
Mailing Address - Fax:916-250-0378
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:307-672-1000
Practice Address - Fax:307-674-5405
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17248A207RX0202X
CAA910160174400000X
CAA91016207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No174400000XOther Service ProvidersSpecialist
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABN374ZMedicare PIN
I35759Medicare UPIN