Provider Demographics
NPI:1033120118
Name:YI, KI SANG (DPM)
Entity Type:Individual
Prefix:MR
First Name:KI
Middle Name:SANG
Last Name:YI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 TERMINO AVE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2124
Mailing Address - Country:US
Mailing Address - Phone:562-597-5100
Mailing Address - Fax:562-597-5165
Practice Address - Street 1:1703 TERMINO AVE
Practice Address - Street 2:SUITE #103
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2124
Practice Address - Country:US
Practice Address - Phone:562-597-5100
Practice Address - Fax:562-597-5165
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4250213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E42500Medicaid
CAE4250AOtherPALMETTO GBA
CAE4250AOtherPALMETTO GBA
CAU78991Medicare UPIN
CAE4250Medicare ID - Type Unspecified
CA000E42500Medicaid