Healthcare Provider Details

I. General information

NPI: 1609815224
Provider Name (Legal Business Name): PETER LEE KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 BAKER ST STE A101
COSTA MESA CA
92626-4407
US

IV. Provider business mailing address

PO BOX 2218
SUISUN CITY CA
94585-5218
US

V. Phone/Fax

Practice location:
  • Phone: 714-668-2500
  • Fax: 714-668-2515
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG77031
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG77031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: