Provider Demographics
NPI:1790892115
Name:KIM, JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
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 1:3000 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2516
Mailing Address - Country:US
Mailing Address - Phone:213-380-1388
Mailing Address - Fax:
Practice Address - Street 1:3000 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2516
Practice Address - Country:US
Practice Address - Phone:213-380-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52950207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G529500Medicaid
CAB57951Medicare UPIN
CAG52950Medicare ID - Type Unspecified