Provider Demographics
NPI:1932408572
Name:KIM, GRACE SANG (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:SANG
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 VIA MARISOL
Mailing Address - Street 2:#724
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-5078
Mailing Address - Country:US
Mailing Address - Phone:818-640-3053
Mailing Address - Fax:
Practice Address - Street 1:1720 E CESAR E CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2414
Practice Address - Country:US
Practice Address - Phone:323-260-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine