Provider Demographics
NPI:1225456098
Name:KIM, LISA TAEHYUNG (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:TAEHYUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2888
Mailing Address - Fax:
Practice Address - Street 1:1220 ROSSMOOR PKWY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595
Practice Address - Country:US
Practice Address - Phone:925-647-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15056207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine