Basic Information
| Provider Information | |||||||||
| NPI: | 1033179072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JINKYU | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 S WESTLAKE BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | WESTLAKE VILLAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913611929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054950551 | ||||||||
| FaxNumber: | 8054968079 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 S WESTLAKE BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | WESTLAKE VILLAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913611929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054950551 | ||||||||
| FaxNumber: | 8054968079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 08/26/2010 | ||||||||
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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 | 174400000X | A75169 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1033179072 | 01 | CA | NPI | OTHER |