1679861694 NPI number — YOUNG MIN KIM M.D.

Table of content: YOUNG MIN KIM M.D. (NPI 1679861694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679861694 NPI number — YOUNG MIN KIM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
YOUNG
Provider Middle Name:
MIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIM
Provider Other First Name:
YOUNG-MIN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1679861694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11175 CAMPUS STREET
Provider Second Line Business Mailing Address:
DEPARTMENT OF PEDIATRICS, COLEMAN PAVILLION
Provider Business Mailing Address City Name:
LOMA LINDA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-558-8291
Provider Business Mailing Address Fax Number:
909-558-0440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 E CAROLINE ST
Provider Second Line Business Practice Location Address:
J WEST
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92408-3747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-835-1810
Provider Business Practice Location Address Fax Number:
909-835-1780
Provider Enumeration Date:
07/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  2011015241 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0402X , with the licence number: A141523 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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