Provider Demographics
NPI:1750309365
Name:KIM, RHODORA ESTACIO (MD)
Entity Type:Individual
Prefix:
First Name:RHODORA
Middle Name:ESTACIO
Last Name:KIM
Suffix:
Gender:F
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:18460 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4107
Practice Address - Country:US
Practice Address - Phone:818-837-5790
Practice Address - Fax:818-998-2506
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71519208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A715190Medicaid
CAE46724Medicare UPIN
CA00A715190Medicaid