Provider Demographics
NPI:1144244690
Name:KIM, TAELL TED (MD)
Entity Type:Individual
Prefix:
First Name:TAELL
Middle Name:TED
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S LAKE AVE
Mailing Address - Street 2:535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:818-546-5632
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG72179207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G721790OtherBLUE SHIELD
CA00G721790Medicaid
CAG72179AMedicare ID - Type Unspecified
CA00G721790Medicaid