Provider Demographics
NPI:1659516094
Name:ILKYOON KIM MD A PROF CORP
Entity Type:Organization
Organization Name:ILKYOON KIM MD A PROF CORP
Other - Org Name:SAME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ILKYOON
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-994-4210
Mailing Address - Street 1:15666 18TH AVE
Mailing Address - Street 2:P.O. BOX 5326
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9336
Mailing Address - Country:US
Mailing Address - Phone:707-994-4210
Mailing Address - Fax:707-994-0839
Practice Address - Street 1:15666 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9336
Practice Address - Country:US
Practice Address - Phone:707-994-4210
Practice Address - Fax:707-994-0839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILKYOON KIM MD A PROF CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-15
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-34081302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A340810Medicaid