Provider Demographics
NPI:1558474262
Name:KIM, CLEMENT CHANGBUM (MD)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:CHANGBUM
Last Name:KIM
Suffix:
Gender:M
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5637
Mailing Address - Fax:818-837-5589
Practice Address - Street 1:26357 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4488
Practice Address - Country:US
Practice Address - Phone:661-222-2658
Practice Address - Fax:661-222-2663
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64821208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A648210Medicaid
CAWA64821AMedicare PIN
CAG88396Medicare UPIN