Provider Demographics
NPI:1518987825
Name:IM, CAROL Y (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:Y
Last Name:IM
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1450 TREAT BLVD
Mailing Address - Street 2:STE 300
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 CIVIC DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-1988
Practice Address - Country:US
Practice Address - Phone:925-676-1700
Practice Address - Fax:925-676-1792
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA80693208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A806930Medicaid
I08761Medicare UPIN
CADK765ZMedicare PIN
CA00A806930Medicaid