Provider Demographics
NPI:1295910958
Name:KIM, CHIN GOO (MD)
Entity type:Individual
Prefix:DR
First Name:CHIN
Middle Name:GOO
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 1:3400 W BALL RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3738
Mailing Address - Country:US
Mailing Address - Phone:714-761-0759
Mailing Address - Fax:714-761-3758
Practice Address - Street 1:3400 W BALL RD STE 208
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3735
Practice Address - Country:US
Practice Address - Phone:714-761-0759
Practice Address - Fax:714-761-3758
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34967174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88312Medicare UPIN