Provider Demographics
NPI:1518920735
Name:KIM, SUNDRA S (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNDRA
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5712 LOS PATIOS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-9729
Mailing Address - Country:US
Mailing Address - Phone:432-704-1484
Mailing Address - Fax:
Practice Address - Street 1:1381 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3314
Practice Address - Country:US
Practice Address - Phone:707-433-5494
Practice Address - Fax:707-385-2157
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5412207RG0300X
CAG43226207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH5412OtherTEXAS STATE MEDICAL LICENSE
CAG43226OtherCALIFORNIA STATE MEDICAL LICENSE
OK731310891006OtherUNICARE
OK1324230001OtherPALMETTO DME
TXBOO70121OtherDPS
OKP00249003OtherRR MEDICARE (PALMETTO)
OK200037600AMedicaid
OKG23047OtherSTERLING OPTION 1
OK200037600AMedicaid
OKP00249003OtherRR MEDICARE (PALMETTO)
OKG23047Medicare UPIN