MEDICARE: STEVEN PARK KIM D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	E4506	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01011615	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306877006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN PARK KIM D.P.M.

Provider Business Mailing Address
First Line	:	3536 MENDOCINO AVE
Second Line	:	200
City	:	SANTA ROSA
State	:	CA
Zip	:	95403-3634
Country	:	US
Telephone Number	:	707-575-6049
Fax Number	:	707-545-0575

Provider Business Practice Location Address
First Line	:	4761 HOEN AVE
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7862
Country	:	US
Telephone Number	:	707-545-0570
Fax Number	:	707-545-0575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	04/18/2012

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Directions to “ STEVEN PARK KIM D.P.M.” Practice Location

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