Provider Demographics
NPI:1679619092
Name:KIM, EDWARD T (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
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 1:2222 EAST ST STE 305
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2066
Mailing Address - Country:US
Mailing Address - Phone:925-686-1230
Mailing Address - Fax:925-686-8443
Practice Address - Street 1:2222 EAST ST STE 305
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2066
Practice Address - Country:US
Practice Address - Phone:925-686-1230
Practice Address - Fax:925-686-8443
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100042207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0020610Medicaid
ZZZ96217Z1Medicare PIN