Basic Information
| Provider Information | |||||||||
| NPI: | 1629011366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | TCHANG | ||||||||
| MiddleName: | JUN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 775 | ||||||||
| Address2: | 12900A GARDEN GROVE BLVD STE #122 | ||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146360242 | ||||||||
| FaxNumber: | 7146360291 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 A GARDEN GROVE BLVD | ||||||||
| Address2: | STE #122 | ||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146360342 | ||||||||
| FaxNumber: | 7146360391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/22/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A29337 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A293370 | 05 | CA | MEDICAID |