Provider Demographics
NPI:1376811380
Name:KIM, CHAE
Entity Type:Individual
Prefix:
First Name:CHAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
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 54679
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0679
Mailing Address - Country:US
Mailing Address - Phone:310-248-7133
Mailing Address - Fax:310-248-7044
Practice Address - Street 1:8767 WILSHIRE BLVD FL 3
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2714
Practice Address - Country:US
Practice Address - Phone:310-248-7190
Practice Address - Fax:424-314-8735
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine