Provider Demographics
NPI:1134223134
Name:KIM, ISAAC KWANGNYON (MD)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:KWANGNYON
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 1:1125 E BROADWAY
Mailing Address - Street 2:BOX 71
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1315
Mailing Address - Country:US
Mailing Address - Phone:818-500-5586
Mailing Address - Fax:818-500-5583
Practice Address - Street 1:4476 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6359
Practice Address - Country:US
Practice Address - Phone:323-825-8300
Practice Address - Fax:866-372-2719
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A879720Medicaid
CA00A879721Medicare PIN
CAI15169Medicare UPIN
CA00A879720Medicaid
CA00A879720Medicare PIN