Provider Demographics
NPI:1114122645
Name:KIM, SAM YONG (IDC)
Entity Type:Individual
Prefix:MR
First Name:SAM
Middle Name:YONG
Last Name:KIM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 DILLON DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-4230
Mailing Address - Country:US
Mailing Address - Phone:619-961-8745
Mailing Address - Fax:
Practice Address - Street 1:BOX 555697
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:AE
Practice Address - Phone:619-961-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman