Provider Demographics
NPI:1619064904
Name:KIM, YOUNG SONG (MD)
Entity Type:Individual
Prefix:
First Name:YOUNG SONG
Middle Name:
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 1:80539 PEBBLE BCH
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4627
Mailing Address - Country:US
Mailing Address - Phone:760-564-0241
Mailing Address - Fax:760-564-5941
Practice Address - Street 1:80539 PEBBLE BCH
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4627
Practice Address - Country:US
Practice Address - Phone:760-564-0241
Practice Address - Fax:760-564-5941
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36986208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC36986Medicare ID - Type UnspecifiedMEDICARE