Provider Demographics
NPI:1205833563
Name:KIM, KENNETH T (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:T
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 1:2600 REDONDO AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2330
Mailing Address - Country:US
Mailing Address - Phone:562-997-7888
Mailing Address - Fax:
Practice Address - Street 1:2600 REDONDO AVE
Practice Address - Street 2:STE 400
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2330
Practice Address - Country:US
Practice Address - Phone:562-997-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG061259207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E36029Medicare UPIN