Provider Demographics
NPI:1417089863
Name:KIM, ROLAND YONGCHUL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:YONGCHUL
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD
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 10322
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838-6322
Mailing Address - Country:US
Mailing Address - Phone:213-804-7346
Mailing Address - Fax:
Practice Address - Street 1:8345 GARDEN GROVE BLVD
Practice Address - Street 2:207
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1133
Practice Address - Country:US
Practice Address - Phone:714-537-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP17823GMedicare ID - Type Unspecified
CACP17823BMedicare ID - Type Unspecified
CACP17823CMedicare ID - Type Unspecified