Basic Information
| Provider Information | |||||||||
| NPI: | 1609854231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YANG | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 S SANTA ANITA ST | ||||||||
| Address2: | STE 320 | ||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917761154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264580181 | ||||||||
| FaxNumber: | 6264580183 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 S SANTA ANITA ST | ||||||||
| Address2: | STE 320 | ||||||||
| City: | SAN GABRIEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917761154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264580181 | ||||||||
| FaxNumber: | 6264580183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 12/26/2007 | ||||||||
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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 | 2084N0400X | A40824 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00A408240 | 05 | CA | MEDICAID |