Basic Information
| Provider Information | |||||||||
| NPI: | 1760446454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KYUNG | ||||||||
| MiddleName: | CHUL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 N TUSTIN AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008837243 | ||||||||
| FaxNumber: | 7146471245 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | NATIONAL CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919502026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194704321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 12/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A36758 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A367580 | 05 | CA | MEDICAID |