Provider Demographics
NPI:1720152507
Name:KIM, CHANG O (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:O
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 1:80 GRAND AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3725
Mailing Address - Country:US
Mailing Address - Phone:510-451-6266
Mailing Address - Fax:510-451-6260
Practice Address - Street 1:80 GRAND AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3725
Practice Address - Country:US
Practice Address - Phone:510-451-6266
Practice Address - Fax:510-451-6260
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82792207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIZ9093Medicare UPIN