Provider Demographics
NPI:1477882215
Name:KIM, KYOUNG AE (MD)
Entity Type:Individual
Prefix:
First Name:KYOUNG
Middle Name:AE
Last Name:KIM
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 1:1211 W LA PALMA AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2815
Mailing Address - Country:US
Mailing Address - Phone:714-772-8282
Mailing Address - Fax:714-772-6493
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2815
Practice Address - Country:US
Practice Address - Phone:714-772-8282
Practice Address - Fax:714-772-6493
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110263208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1102630Medicaid
CADU898WMedicare PIN
CADU898ZMedicare PIN
CADU898XMedicare PIN
CADU898YMedicare PIN