Provider Demographics
NPI:1619355492
Name:KIM, OK SANG (CCP)
Entity Type:Individual
Prefix:
First Name:OK
Middle Name:SANG
Last Name:KIM
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 EMPIRE WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1747
Mailing Address - Country:US
Mailing Address - Phone:916-802-8880
Mailing Address - Fax:
Practice Address - Street 1:4218 EMPIRE WAY
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1747
Practice Address - Country:US
Practice Address - Phone:916-802-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB3805516242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist