Provider Demographics
NPI:1205924800
Name:KIM, SOO Y (MD)
Entity type:Individual
Prefix:
First Name:SOO
Middle Name:Y
Last Name:KIM
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 1:1187 E HERNDON AVE
Mailing Address - Street 2:#101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3166
Mailing Address - Country:US
Mailing Address - Phone:559-440-0450
Mailing Address - Fax:559-440-0460
Practice Address - Street 1:1187 E HERNDON AVE
Practice Address - Street 2:#101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3166
Practice Address - Country:US
Practice Address - Phone:559-440-0450
Practice Address - Fax:559-440-0460
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG86091207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF78412Medicare UPIN