Provider Demographics
NPI:1497806566
Name:KIM, WALTER J I (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:J
Last Name:KIM
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WALTER
Other - Middle Name:J
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4160 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3500
Mailing Address - Country:US
Mailing Address - Phone:323-965-9650
Mailing Address - Fax:323-965-9690
Practice Address - Street 1:4160 WILSHIRE BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3500
Practice Address - Country:US
Practice Address - Phone:323-965-9650
Practice Address - Fax:323-965-9690
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17138Medicare UPIN