Provider Demographics
NPI:1609011204
Name:KIM, EDWARD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:THOMAS
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-3045
Mailing Address - Fax:951-248-6760
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2658
Practice Address - Country:US
Practice Address - Phone:951-782-3725
Practice Address - Fax:951-784-3267
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301102651207R00000X, 207RC0000X, 207RC0001X
390200000X
CAA136939207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program