Provider Demographics
NPI:1407990955
Name:KIM, TERRENCE T (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:T
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 1:444 S SAN VICENTE BLVD
Mailing Address - Street 2:MARK GOODSON BLDG., SUITE 800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4165
Mailing Address - Country:US
Mailing Address - Phone:310-423-9716
Mailing Address - Fax:310-423-9767
Practice Address - Street 1:444 S SAN VICENTE BLVD
Practice Address - Street 2:MARK GOODSON BLDG., SUITE 800
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4165
Practice Address - Country:US
Practice Address - Phone:310-423-9716
Practice Address - Fax:310-423-9767
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103614207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTAN BC049YMedicare PIN