Provider Demographics
NPI:1942798509
Name:PAIK, KACIE KYUNGSUN (MD)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:KYUNGSUN
Last Name:PAIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14350 MERIDIAN PKWY # 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92518-3035
Mailing Address - Country:US
Mailing Address - Phone:951-827-7669
Mailing Address - Fax:951-827-4280
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:629-543-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-28
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165648390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program