Healthcare Provider Details

I. General information

NPI: 1013479997
Provider Name (Legal Business Name): GRACE CHARMIE KIM MD, MPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SIERRA PARK RD # A
MAMMOTH LAKES CA
93546-2073
US

IV. Provider business mailing address

85 SIERRA PARK RD
MAMMOTH LAKES CA
93546-2073
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA178510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: