Provider Demographics
NPI:1699858993
Name:KIM, ANDREW J (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
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 1:3663 W 6TH ST STE 309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3050
Mailing Address - Country:US
Mailing Address - Phone:213-387-8200
Mailing Address - Fax:213-365-2600
Practice Address - Street 1:3663 W 6TH ST STE 309
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3050
Practice Address - Country:US
Practice Address - Phone:213-387-8200
Practice Address - Fax:213-365-2600
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49072174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF75944Medicare UPIN