Provider Demographics
NPI:1336221969
Name:KIM, CHAN H (MD)
Entity Type:Individual
Prefix:
First Name:CHAN
Middle Name:H
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 1:14350 WHITTIER BLVD
Mailing Address - Street 2:SUITE #320
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90605-2138
Mailing Address - Country:US
Mailing Address - Phone:562-696-2622
Mailing Address - Fax:562-696-5630
Practice Address - Street 1:14350 WHITTIER BLVD
Practice Address - Street 2:SUITE #320
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90605-2138
Practice Address - Country:US
Practice Address - Phone:562-696-2622
Practice Address - Fax:562-696-5630
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA307322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA30732Medicare ID - Type Unspecified
A84119Medicare UPIN