Provider Demographics
NPI:1013411602
Name:KIM, IRENE (DO)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27190 SUN CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-5505
Mailing Address - Country:US
Mailing Address - Phone:951-723-3804
Mailing Address - Fax:951-723-3806
Practice Address - Street 1:27190 SUN CITY BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-5505
Practice Address - Country:US
Practice Address - Phone:951-723-3804
Practice Address - Fax:951-723-3806
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17984207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine