Healthcare Provider Details

I. General information

NPI: 1457633919
Provider Name (Legal Business Name): DONG H KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2011
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 LONG BEACH BLVD RAD-IMAGE MEDICAL GROUP INC.
LONG BEACH CA
90807-2003
US

IV. Provider business mailing address

4241 LONG BEACH BLVD RAD-IMAGE MEDICAL GROUP INC.
LONG BEACH CA
90807-2003
US

V. Phone/Fax

Practice location:
  • Phone: 562-912-2507
  • Fax: 484-918-2507
Mailing address:
  • Phone: 562-912-2507
  • Fax: 484-918-2507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA112453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: