Provider Demographics
NPI:1225299688
Name:YANG-KIM, DOMINIQUE B (DO)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:B
Last Name:YANG-KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:BEVERLY
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9110 FAIRLAND ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4434
Mailing Address - Country:US
Mailing Address - Phone:626-394-1408
Mailing Address - Fax:
Practice Address - Street 1:5253 PRUE RD STE 315C
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1758
Practice Address - Country:US
Practice Address - Phone:210-750-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAXXXX207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15019054OtherCAQH