Provider Demographics
NPI:1578660916
Name:KIM, ERIC E (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:E
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 1500
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-1500
Mailing Address - Country:US
Mailing Address - Phone:707-994-9191
Mailing Address - Fax:707-994-9090
Practice Address - Street 1:4456 MANZANITA AVE
Practice Address - Street 2:SUITE# C
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-7937
Practice Address - Country:US
Practice Address - Phone:707-994-9191
Practice Address - Fax:707-994-9090
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64242207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A642420Medicaid
CA2113132OtherMEDI-CAL UPIN #
CACL280AMedicare PIN
CA00A642420Medicaid