Provider Demographics
NPI:1851443071
Name:HARGIS, KIM M (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:M
Last Name:HARGIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:LATTIMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:PHR GROUP & PROVIDER ENROLLMENT UNIT, 3RD FLR
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7966
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1702
Practice Address - Country:US
Practice Address - Phone:323-857-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84435208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A844350Medicaid
00A844350Medicare ID - Type Unspecified
CA00A844350Medicaid