Basic Information
| Provider Information | |||||||||
| NPI: | 1003915661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 EAST SEVENTH STREET | ||||||||
| Address2: | DVAMC (05/113NP) | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628265513 | ||||||||
| FaxNumber: | 5628265623 | ||||||||
| Practice Location | |||||||||
| Address1: | 5901 EAST SEVENTH STREET | ||||||||
| Address2: | DVAMC (05/113NP) | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628265513 | ||||||||
| FaxNumber: | 5628265623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZN0500X | G13550 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Neuropathology |
ID Information
| ID | Type | State | Issuer | Description | WG13550A | 01 | CA | MEDICARE PTAN | OTHER | 00G135500 | 01 | CA | BLUE SHIELD | OTHER | 00G135500 | 05 | CA | MEDICAID | 220027744 | 01 | CA | RAILROAD MEDICARE | OTHER |