Provider Demographics
NPI:1013479997
Name:KIM, GRACE CHARMIE (MD, MPP)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CHARMIE
Last Name:KIM
Suffix:
Gender:F
Credentials:MD, MPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5630 VENICE BLVD # 1037
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-5127
Mailing Address - Country:US
Mailing Address - Phone:253-653-4173
Mailing Address - Fax:
Practice Address - Street 1:85 SIERRA PARK RD # A
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2073
Practice Address - Country:US
Practice Address - Phone:760-924-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178510208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics