Provider Demographics
NPI:1740276989
Name:KIM, GRACE L (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:L
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6406
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-6406
Mailing Address - Country:US
Mailing Address - Phone:805-928-1731
Mailing Address - Fax:805-349-8160
Practice Address - Street 1:805 AEROVISTA PL
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7919
Practice Address - Country:US
Practice Address - Phone:805-541-1595
Practice Address - Fax:805-594-1241
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2015-03-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA48699207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A486990Medicaid
CAG26462Medicare UPIN
CA00A486990Medicaid