Provider Demographics
NPI:1225501109
Name:KIM, ELIJAH SANGKU-DANIEL
Entity Type:Individual
Prefix:MR
First Name:ELIJAH
Middle Name:SANGKU-DANIEL
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ELIJAH
Other - Middle Name:SANGKU-DANIEL
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 15586
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-260-5997
Mailing Address - Fax:
Practice Address - Street 1:200 MERCY CIRCLE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:415-260-5997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19455363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty