Provider Demographics
NPI:1073939815
Name:KIM, KISUNG (BM)
Entity Type:Individual
Prefix:
First Name:KISUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:BM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 SISTER MARY COLUMBA DR
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-4356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4356
Practice Address - Country:US
Practice Address - Phone:530-527-0414
Practice Address - Fax:530-527-3720
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1412072080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine