Healthcare Provider Details

I. General information

NPI: 1518920735
Provider Name (Legal Business Name): SUNDRA S KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 E CENTURY BLVD
LOS ANGELES CA
90002-3050
US

IV. Provider business mailing address

1776 E CENTURY BLVD
LOS ANGELES CA
90002-3050
US

V. Phone/Fax

Practice location:
  • Phone: 323-374-6848
  • Fax: 323-374-6691
Mailing address:
  • Phone: 323-374-6848
  • Fax: 323-374-6691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberH5412
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberG43226
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG43226
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: