Provider Demographics
NPI:1598816688
Name:SWANSON, KIM T (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:T
Last Name:SWANSON
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
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Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8728
Mailing Address - Country:US
Mailing Address - Phone:949-721-1708
Mailing Address - Fax:949-721-1757
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8728
Practice Address - Country:US
Practice Address - Phone:949-721-1708
Practice Address - Fax:949-721-1757
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2016-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG60832207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG60832OtherMEDICAL LICENSE #
CAA02022Medicare UPIN