Provider Demographics
NPI:1730124306
Name:ALYSSA YOUNGJEE KIM MD A PROF CORP
Entity Type:Organization
Organization Name:ALYSSA YOUNGJEE KIM MD A PROF CORP
Other - Org Name:ALYSSA YOUNGJEE KIM, M.D., A PROFESSIONAL CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-786-0908
Mailing Address - Street 1:6521 E YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-2469
Mailing Address - Country:US
Mailing Address - Phone:949-786-0908
Mailing Address - Fax:714-998-7314
Practice Address - Street 1:14150 CULVER DR
Practice Address - Street 2:SUITE 304
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0315
Practice Address - Country:US
Practice Address - Phone:949-786-0908
Practice Address - Fax:949-786-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 70663207N00000X, 207ND0900X, 207NS0135X
CAG70663207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W18474Medicare ID - Type Unspecified
Y28349Medicare UPIN