1962475624 NPI number — BO K KIM MD

Table of content: BO K KIM MD (NPI 1962475624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962475624 NPI number — BO K KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
BO
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1962475624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
145 VISTA AVE
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91107-3607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-397-8335
Provider Business Mailing Address Fax Number:
626-397-8350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 E CALIFORNIA BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91105-3954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-449-7350
Provider Business Practice Location Address Fax Number:
626-449-1321
Provider Enumeration Date:
02/10/2006

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: 208000000X , with the licence number:  A70312 , 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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