Basic Information
| Provider Information | |||||||||
| NPI: | 1477882215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KYOUNG | ||||||||
| MiddleName: | AE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 W LA PALMA AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928012815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147728282 | ||||||||
| FaxNumber: | 7147726493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 W LA PALMA AVE | ||||||||
| Address2: | SUITE 207 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928012815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147728282 | ||||||||
| FaxNumber: | 7147726493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A110263 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | A110263 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A1102630 | 05 | CA | MEDICAID |