Provider Demographics
NPI:1275545543
Name:KIM, ROY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
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:PO BOX 1897
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476
Mailing Address - Country:US
Mailing Address - Phone:415-827-0344
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:RM 1440
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4010
Practice Address - Country:US
Practice Address - Phone:415-362-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84287208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75987Medicare UPIN
CA00G842870Medicare ID - Type Unspecified