Healthcare Provider Details

I. General information

NPI: 1790779791
Provider Name (Legal Business Name): STANLEY TAESON KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8762
US

IV. Provider business mailing address

1510 E HERNDON AVE STE 110
FRESNO CA
93720-3333
US

V. Phone/Fax

Practice location:
  • Phone: 559-485-8330
  • Fax:
Mailing address:
  • Phone: 559-485-8330
  • Fax: 559-485-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberC151887
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC151887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: