Provider Demographics
NPI:1619987054
Name:KIM, WAYNE W (DO)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12362 BEACH BLVD STE 10
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3944
Mailing Address - Country:US
Mailing Address - Phone:714-248-9500
Mailing Address - Fax:714-622-4943
Practice Address - Street 1:12362 BEACH BLVD STE 10
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3944
Practice Address - Country:US
Practice Address - Phone:714-248-9500
Practice Address - Fax:714-622-4943
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001562207Q00000X, 207QA0401X
261QC1500X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid