Healthcare Provider Details

I. General information

NPI: 1639141773
Provider Name (Legal Business Name): ILKWON KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 S WILTON PL APT 402
LOS ANGELES CA
90020-4586
US

IV. Provider business mailing address

412 S. WILTON PLACE UNIT 402
LOS ANGELES CA
90020
US

V. Phone/Fax

Practice location:
  • Phone: 121-380-0101
  • Fax: 213-800-1010
Mailing address:
  • Phone: 12138001010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC50652
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC50652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: