Healthcare Provider Details

I. General information

NPI: 1487733754
Provider Name (Legal Business Name): TAI-WON KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVENUE, SUITE 9A
BUENA PARK CA
90621-4668
US

IV. Provider business mailing address

451 WEST LINCOLN AVENUE SUITE 100
ANAHEIM CA
92805-2912
US

V. Phone/Fax

Practice location:
  • Phone: 714-503-6550
  • Fax: 714-409-3075
Mailing address:
  • Phone: 714-503-6550
  • Fax: 714-409-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC50240
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37571
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: