Healthcare Provider Details

I. General information

NPI: 1730124306
Provider Name (Legal Business Name): ALYSSA YOUNGJEE KIM MD A PROF CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 CULVER DR SUITE 304
IRVINE CA
92604-0315
US

IV. Provider business mailing address

6521 E YOSEMITE AVE
ORANGE CA
92867-2469
US

V. Phone/Fax

Practice location:
  • Phone: 949-786-0908
  • Fax: 949-786-0970
Mailing address:
  • Phone: 949-786-0908
  • Fax: 714-998-7314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberG 70663
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberG70663
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberG 70663
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberG 70663
License Number StateCA

VIII. Authorized Official

Name: DR. ALYSSA Y. KIM
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 949-786-0908