Provider Demographics
NPI:1831109578
Name:SIM, KENNETH T (MD)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:SIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:120 W HELLMAN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1209
Mailing Address - Country:US
Mailing Address - Phone:626-457-6333
Mailing Address - Fax:626-457-1933
Practice Address - Street 1:120 W HELLMAN AVE STE 203
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1209
Practice Address - Country:US
Practice Address - Phone:626-457-6333
Practice Address - Fax:626-457-1933
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA40177208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401770Medicaid
CA00A401770Medicaid
CAA40177Medicare ID - Type Unspecified