Basic Information
| Provider Information | |||||||||
| NPI: | 1679619092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 EAST ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 EAST ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945202066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256861230 | ||||||||
| FaxNumber: | 9256868443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | A100042 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | GR0020610 | 05 | CA | MEDICAID |