Provider Demographics
NPI:1508820531
Name:KIM, SUZY (MD)
Entity Type:Individual
Prefix:
First Name:SUZY
Middle Name:
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 1:5 JOURNEY
Mailing Address - Street 2:STE 210
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5332
Mailing Address - Country:US
Mailing Address - Phone:949-305-7122
Mailing Address - Fax:949-305-7160
Practice Address - Street 1:2767 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6713
Practice Address - Country:US
Practice Address - Phone:714-578-8706
Practice Address - Fax:714-578-8715
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA865592081P0004X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A865590Medicaid
CA00A865590Medicaid
CA00A865590Medicare ID - Type Unspecified