Provider Demographics
NPI:1235222902
Name:KIM, E. EDMUND (MD)
Entity Type:Individual
Prefix:DR
First Name:E.
Middle Name:EDMUND
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 1:16100 SAND CANYON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3721
Mailing Address - Country:US
Mailing Address - Phone:713-792-3008
Mailing Address - Fax:713-792-4580
Practice Address - Street 1:16100 SAND CANYON AVE STE 130
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3722
Practice Address - Country:US
Practice Address - Phone:713-792-3008
Practice Address - Fax:713-792-4580
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG04482085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124031901Medicaid
TX800323OtherBCBS
E30394Medicare UPIN
TX124031901Medicaid