Provider Demographics
NPI:1760530786
Name:KIM, THOMAS DONG (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DONG
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 1:1310 W STEWART DR
Mailing Address - Street 2:SUITE 410
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:714-639-4105
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 410
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:714-639-4105
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90400207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912919804OtherNPI TYPE 2
CAP00460300OtherRAIL ROAD MEDICARE PROVIDER PTAN
CACG5665OtherRAIL ROAD MEDICARE GROUP PTAN
1912919804OtherNPI TYPE 2
CAW1514Medicare PIN
CAW1514OtherMEDICARE PTAN TYPE 2
CA00A904000Medicaid