Provider Demographics
NPI:1588077564
Name:KIM, SHANNON LEUNG
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7910 FROST STREET
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-496-4800
Mailing Address - Fax:
Practice Address - Street 1:8910 VILLA LA JOLLA DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-203-4962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA162026208000000X
MA260164208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics