Provider Demographics
NPI:1629267943
Name:TCHANG JUN KIM MD INC
Entity Type:Organization
Organization Name:TCHANG JUN KIM MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TCHANG
Authorized Official - Middle Name:JUN
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:714-636-0342
Mailing Address - Street 1:PO BOX 775
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-0775
Mailing Address - Country:US
Mailing Address - Phone:714-636-0342
Mailing Address - Fax:714-636-0342
Practice Address - Street 1:12601 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1908
Practice Address - Country:US
Practice Address - Phone:714-537-5160
Practice Address - Fax:714-590-2489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29337207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A293370Medicaid
CAA29337Medicare PIN
CAE01594Medicare UPIN