Provider Demographics
NPI:1306846399
Name:YI, KYONG MIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KYONG
Middle Name:MIN
Last Name:YI
Suffix:
Gender:F
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 3379
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96160-3379
Mailing Address - Country:US
Mailing Address - Phone:408-228-2357
Mailing Address - Fax:408-993-8555
Practice Address - Street 1:1460 G ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4112
Practice Address - Country:US
Practice Address - Phone:541-726-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD189845208600000X
NV18168208600000X
CAG85233208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH06333Medicare UPIN