Provider Demographics
NPI:1457409476
Name:KIM-WAKAMATSU, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:KIM-WAKAMATSU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:KIM
Other - Last Name:WAKAMATSU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 HOAG DRIVE
Mailing Address - Street 2:POB 6100-ED
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-6100
Mailing Address - Country:US
Mailing Address - Phone:949-764-5689
Mailing Address - Fax:
Practice Address - Street 1:1 HOAG DRIVE
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92658-6100
Practice Address - Country:US
Practice Address - Phone:949-764-5689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89026207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine