Provider Demographics
NPI:1679861694
Name:KIM, YOUNG MIN (MD)
Entity Type:Individual
Prefix:
First Name:YOUNG
Middle Name:MIN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YOUNG-MIN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11175 CAMPUS STREET
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS, COLEMAN PAVILLION
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-8291
Mailing Address - Fax:909-558-0440
Practice Address - Street 1:250 E CAROLINE ST
Practice Address - Street 2:J WEST
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3747
Practice Address - Country:US
Practice Address - Phone:909-835-1810
Practice Address - Fax:909-835-1780
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011015241208000000X
CAA1415232084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics