Provider Demographics
NPI:1992715437
Name:KIM, KASEY (MD)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KYUNG CHUN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1417 WEST LOMITA BLVD
Mailing Address - Street 2:#2
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710
Mailing Address - Country:US
Mailing Address - Phone:213-219-4401
Mailing Address - Fax:310-891-1890
Practice Address - Street 1:10802 COLLEGE PLACE
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703
Practice Address - Country:US
Practice Address - Phone:562-924-9581
Practice Address - Fax:562-924-6523
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3519336OtherMEDI-CAL
CAA83569Medicare ID - Type Unspecified
I24665Medicare UPIN