Provider Demographics
NPI:1710978770
Name:KIM, RICHARD T (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 RED APPLE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3961
Mailing Address - Country:US
Mailing Address - Phone:949-654-2977
Mailing Address - Fax:949-654-2977
Practice Address - Street 1:6 WILLARD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4694
Practice Address - Country:US
Practice Address - Phone:949-262-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX67740Medicaid
CAW20A6774EMedicare ID - Type Unspecified
CA00AX67740Medicaid