Provider Demographics
NPI:1982818720
Name:KIM, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
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 1:1855 S MAIN ST
Mailing Address - Street 2:SUITE A, HEART & VASCULAR CENTER
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4852
Mailing Address - Country:US
Mailing Address - Phone:574-533-7476
Mailing Address - Fax:574-533-7145
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-5282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079733207RC0000X
IN01067672207RC0000X
CAA108581207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200972580Medicaid
184520ZZZMedicare Oscar/Certification