Provider Demographics
NPI:1750902003
Name:KIM, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
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 1:3231 EUCLID AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4603
Mailing Address - Country:US
Mailing Address - Phone:708-783-2000
Mailing Address - Fax:708-783-3656
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:323-541-1661
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA185019207Q00000X
IL125.076158207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine