Healthcare Provider Details

I. General information

NPI: 1104147834
Provider Name (Legal Business Name): EUNJEONG KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 EL CAMINO REAL
PALO ALTO CA
94301-2302
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 650-853-2974
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number161592
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: