Provider Demographics
NPI:1720379100
Name:KIM, SAMUEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
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 1:555 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4904
Mailing Address - Country:US
Mailing Address - Phone:909-982-8846
Mailing Address - Fax:909-949-3967
Practice Address - Street 1:555 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4904
Practice Address - Country:US
Practice Address - Phone:909-982-8846
Practice Address - Fax:909-949-3967
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
CAA123812207WX0107X
DCMD042959207W00000X
VA0101257811207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC415522Y2FMedicare PIN