Healthcare Provider Details

I. General information

NPI: 1659694578
Provider Name (Legal Business Name): JUDITH YOUNGME KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 VIA CAMPO
MONTEBELLO CA
90640-1807
US

IV. Provider business mailing address

3919 BEVERLY BLVD
LOS ANGELES CA
90004-3432
US

V. Phone/Fax

Practice location:
  • Phone: 323-837-7230
  • Fax:
Mailing address:
  • Phone: 323-662-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA114255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: