Healthcare Provider Details

I. General information

NPI: 1760001572
Provider Name (Legal Business Name): YO SUP KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 STOCKTON BLVD STE 207
SACRAMENTO CA
95816-7092
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-887-7862
  • Fax: 916-736-5533
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA200645
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: