Basic Information
Provider Information | |||||||||
NPI: | 1174615215 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WANG | ||||||||
FirstName: | KIM | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3301 C ST | ||||||||
Address2: | SUITE #200-E | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958163300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164470621 | ||||||||
Practice Location | |||||||||
Address1: | 3301 C ST | ||||||||
Address2: | SUITE #200-E | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958163300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164476267 | ||||||||
FaxNumber: | 9164470621 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2006 | ||||||||
LastUpdateDate: | 05/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A96087 | CA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | BM269T | 01 | CA | MEDICARE PTAN | OTHER | BM269W | 01 | CA | MEDICARE PTAN | OTHER | BM269U | 01 | CA | MEDICARE PTAN | OTHER | BM269Y | 01 | CA | MEDICARE PTAN | OTHER | A96087 | 05 | CA |   | MEDICAID | BM269V | 01 | CA | MEDICARE PTAN | OTHER | A96087 | 01 | CA | MEDICAL LICENSE NUMBER | OTHER | BM269S | 01 | CA | MEDICARE PTAN | OTHER | BM269X | 01 | CA | MEDICARE PTAN | OTHER | BM269Z | 01 | CA | MEDICARE PTAN | OTHER |