Provider Demographics
NPI:1174303713
Name:KIM, TED
Entity type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 WILSHIRE BLVD STE 414
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4804
Mailing Address - Country:US
Mailing Address - Phone:310-552-9999
Mailing Address - Fax:
Practice Address - Street 1:2811 WILSHIRE BLVD STE 414
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4804
Practice Address - Country:US
Practice Address - Phone:310-552-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant