Provider Demographics
NPI:1184886780
Name:KIM, CARON R
Entity type:Individual
Prefix:
First Name:CARON
Middle Name:R
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5756 W. CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5655
Mailing Address - Country:US
Mailing Address - Phone:310-794-7274
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PLZ
Practice Address - Street 2:SUITE 430
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-7274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111329207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1113290Medicaid
CAGB878ZMedicare PIN