Provider Demographics
NPI:1346415072
Name:KIM, KYUNGROK (MD)
Entity Type:Individual
Prefix:
First Name:KYUNGROK
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 1:20639 KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2428
Mailing Address - Country:US
Mailing Address - Phone:818-434-6025
Mailing Address - Fax:
Practice Address - Street 1:20639 KINGSBURY ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2428
Practice Address - Country:US
Practice Address - Phone:818-434-6025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77040207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00755935Medicare PIN
CAP00865405Medicare PIN
CABQ201YMedicare PIN
CABQ201ZMedicare PIN