Provider Demographics
NPI:1235227760
Name:KIM, NICHOLAS YOUNGRAE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:YOUNGRAE
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:YOUNG
Other - Middle Name:RAE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3010 W ORANGE AVE
Mailing Address - Street 2:#409
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3173
Mailing Address - Country:US
Mailing Address - Phone:714-484-3781
Mailing Address - Fax:714-484-3852
Practice Address - Street 1:3010 W ORANGE AVE
Practice Address - Street 2:#409
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3169
Practice Address - Country:US
Practice Address - Phone:714-484-3781
Practice Address - Fax:714-484-3852
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52615207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A526150Medicaid
G63250Medicare UPIN
CAA52615Medicare ID - Type UnspecifiedSTATE LICENSE NUMBER