Provider Demographics
NPI:1457391773
Name:KIM, KYUNG (MD)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:740 OAK AVENUE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6814
Mailing Address - Country:US
Mailing Address - Phone:916-250-0377
Mailing Address - Fax:916-250-0378
Practice Address - Street 1:1631 CREEKSIDE DR STE 102
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-250-0377
Practice Address - Fax:916-250-0378
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA910160174400000X
CAA91016207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABN374ZMedicare PIN
I35759Medicare UPIN