Provider Demographics
NPI:1104830157
Name:KIM, MICHAEL S (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:KIM
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 1:2727 W OLYMPIC BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2637
Mailing Address - Country:US
Mailing Address - Phone:213-380-7888
Mailing Address - Fax:213-268-7884
Practice Address - Street 1:2727 W OLYMPIC BLVD
Practice Address - Street 2:#100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2637
Practice Address - Country:US
Practice Address - Phone:213-380-7888
Practice Address - Fax:213-268-7884
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4040213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40400Medicaid
CAE4040AMedicare ID - Type Unspecified
CA000E40400Medicaid