1487733754 NPI number — DR. TAI-WON KIM MD

Table of content: DR. TAI-WON KIM MD (NPI 1487733754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487733754 NPI number — DR. TAI-WON KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
TAI-WON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487733754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
451 WEST LINCOLN AVENUE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92805-2912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-503-6550
Provider Business Mailing Address Fax Number:
714-409-3075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7212 ORANGETHORPE AVENUE,
Provider Second Line Business Practice Location Address:
SUITE 9A
Provider Business Practice Location Address City Name:
BUENA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90621-4668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-503-6550
Provider Business Practice Location Address Fax Number:
714-409-3075
Provider Enumeration Date:
11/06/2006

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: 207R00000X , with the licence number:  C50240 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 37571 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0330654 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487733754 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35037571 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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