Healthcare Provider Details

I. General information

NPI: 1003168626
Provider Name (Legal Business Name): PETER C KIM DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 10/03/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4482 BARRANCA PKWY STE 228
IRVINE CA
92604-1738
US

IV. Provider business mailing address

4482 BARRANCA PKWY STE 228
IRVINE CA
92604-1738
US

V. Phone/Fax

Practice location:
  • Phone: 949-379-3080
  • Fax: 949-379-3020
Mailing address:
  • Phone: 949-379-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER CHANG KIM
Title or Position: PRESIDENT
Credential: DPM
Phone: 949-379-3080