Healthcare Provider Details

I. General information

NPI: 1467985994
Provider Name (Legal Business Name): KYU SEO KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 07/23/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17100 EUCLID ST. PICU DEPT.
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

17100 EUCLID ST. PICU DEPT.
FOUNTAIN VALLEY CA
92708
US

V. Phone/Fax

Practice location:
  • Phone: 714-966-7253
  • Fax: 714-966-3354
Mailing address:
  • Phone: 714-966-7253
  • Fax: 714-966-3354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD214632
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA157291
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD214632
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA157291
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: