Provider Demographics
NPI:1275096489
Name:KIM, ERIC TAEJUN
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:TAEJUN
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 W SUNSET BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6021
Mailing Address - Country:US
Mailing Address - Phone:833-574-2273
Mailing Address - Fax:
Practice Address - Street 1:4900 W SUNSET BLVD FL 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5814
Practice Address - Country:US
Practice Address - Phone:323-783-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY05052207Q00000X, 390200000X
CA19826390200000X
CA20A19826207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program