Provider Demographics
NPI:1497835052
Name:KIM, GARY O (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:O
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:O'SEUNG
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:612 W DUARTE RD
Mailing Address - Street 2:#501
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-9206
Mailing Address - Country:US
Mailing Address - Phone:626-821-1112
Mailing Address - Fax:626-821-1118
Practice Address - Street 1:612 W DUARTE RD STE 501
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9206
Practice Address - Country:US
Practice Address - Phone:626-821-1112
Practice Address - Fax:626-821-1118
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23069Medicare UPIN
CAA22444Medicare ID - Type UnspecifiedPHYSICIAN'S LICENSE# CA