Provider Demographics
NPI:1487733754
Name:KIM, TAI-WON (MD)
Entity type:Individual
Prefix:DR
First Name:TAI-WON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:451 WEST LINCOLN AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-2912
Mailing Address - Country:US
Mailing Address - Phone:714-503-6550
Mailing Address - Fax:714-409-3075
Practice Address - Street 1:7212 ORANGETHORPE AVENUE,
Practice Address - Street 2:SUITE 9A
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4668
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:714-409-3075
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC50240207R00000X
OH37571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0330654Medicaid
CA1487733754Medicaid
OH35037571OtherMEDICAL LICENSE
OH4255501Medicare PIN