Healthcare Provider Details

I. General information

NPI: 1255414629
Provider Name (Legal Business Name): CHIWAN KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 CAPITOL AVE RM 1S118
SACRAMENTO CA
95816-6039
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-887-0780
  • Fax: 916-887-0786
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberG88369
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number79532
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: