Healthcare Provider Details

I. General information

NPI: 1013857689
Provider Name (Legal Business Name): SAMUEL KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 E 120TH ST
LOS ANGELES CA
90059-3051
US

IV. Provider business mailing address

11105 ROSE AVE APT 106
LOS ANGELES CA
90034-6039
US

V. Phone/Fax

Practice location:
  • Phone: 323-563-2480
  • Fax:
Mailing address:
  • Phone: 646-509-5923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: