Basic Information
| Provider Information | |||||||||
| NPI: | 1033365341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S ZEDIKER AVE BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | PARLIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936482667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596463561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4770 W HERNDON AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937228401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594500463 | ||||||||
| FaxNumber: | 5594500464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A105129 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | FHC70046F | 05 | CA | MEDICAID |