Healthcare Provider Details

I. General information

NPI: 1265181853
Provider Name (Legal Business Name): MINJI KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BROXTON AVE # 301
LOS ANGELES CA
90024-2801
US

IV. Provider business mailing address

5295 CAMERON DR APT 511
BUENA PARK CA
90621-1309
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-5844
  • Fax:
Mailing address:
  • Phone: 562-299-3803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125.080270
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA201286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: