Healthcare Provider Details

I. General information

NPI: 1851443071
Provider Name (Legal Business Name): KIM M. HARGIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM M. LATTIMORE M.D.

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 CADILLAC AVE
LOS ANGELES CA
90034-1702
US

IV. Provider business mailing address

393 E WALNUT ST PHR GROUP & PROVIDER ENROLLMENT UNIT, 3RD FLR
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 323-857-2000
  • Fax:
Mailing address:
  • Phone: 626-405-7966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036108200
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number036108200
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA84435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: