Provider Demographics
NPI:1942267992
Name:KIM, DONG S (MD)
Entity Type:Individual
Prefix:DR
First Name:DONG
Middle Name:S
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 1:11441 HEACOCK ST
Mailing Address - Street 2:STE F
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7907
Mailing Address - Country:US
Mailing Address - Phone:951-243-8000
Mailing Address - Fax:951-243-9707
Practice Address - Street 1:11441 HEACOCK ST
Practice Address - Street 2:STE F
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7907
Practice Address - Country:US
Practice Address - Phone:951-243-8000
Practice Address - Fax:951-243-9707
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE91494Medicare UPIN
CABR905ZMedicare PIN