Provider Demographics
NPI:1770629792
Name:YIM, KELLEY B (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:B
Last Name:YIM
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 1:3288 MOANALUA RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1469
Mailing Address - Country:US
Mailing Address - Phone:808-432-0000
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:808-432-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-8848207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI078143-01Medicaid
HI0000206714OtherHMSA BILLING NUMBER
HIDI709ZMedicare PIN
HIG29368Medicare UPIN
HI0000206714OtherHMSA BILLING NUMBER