Basic Information
| Provider Information | |||||||||
| NPI: | 1134223134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | ISAAC | ||||||||
| MiddleName: | KWANGNYON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E BROADWAY | ||||||||
| Address2: | BOX 71 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912051315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185005586 | ||||||||
| FaxNumber: | 8185005583 | ||||||||
| Practice Location | |||||||||
| Address1: | 4476 TWEEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | SOUTH GATE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902806359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238258300 | ||||||||
| FaxNumber: | 8663722719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A87972 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A879720 | 05 | CA | MEDICAID |