Provider Demographics
NPI:1629011366
Name:KIM, TCHANG JUN (MD)
Entity Type:Individual
Prefix:
First Name:TCHANG
Middle Name:JUN
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:PO BOX 775
Mailing Address - Street 2:12900A GARDEN GROVE BLVD STE #122
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842
Mailing Address - Country:US
Mailing Address - Phone:714-636-0242
Mailing Address - Fax:714-636-0291
Practice Address - Street 1:12900 A GARDEN GROVE BLVD
Practice Address - Street 2:STE #122
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92842
Practice Address - Country:US
Practice Address - Phone:714-636-0342
Practice Address - Fax:714-636-0391
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29337207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A293370Medicaid
CA00A293370Medicaid
E01594Medicare UPIN