Provider Demographics
NPI:1760644843
Name:KIM, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
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 1:2875 SHEFFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-3029
Mailing Address - Country:US
Mailing Address - Phone:909-725-1135
Mailing Address - Fax:
Practice Address - Street 1:2875 SHEFFIELD RD
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-3029
Practice Address - Country:US
Practice Address - Phone:909-725-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116735208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist