Healthcare Provider Details

I. General information

NPI: 1780237313
Provider Name (Legal Business Name): CHARLES KIM MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39717 CAMINO MISTRAL
INDIO CA
92203-4361
US

IV. Provider business mailing address

2670 N MAIN ST STE 100
SANTA ANA CA
92705-6639
US

V. Phone/Fax

Practice location:
  • Phone: 497-749-9994
  • Fax: 442-268-1717
Mailing address:
  • Phone: 949-527-9009
  • Fax: 442-268-1717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HYE YOUNG SUNG
Title or Position: MEDICAL BILLING
Credential:
Phone: 949-527-9009