Healthcare Provider Details

I. General information

NPI: 1366753022
Provider Name (Legal Business Name): MINA KIM WASSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MINA KIM MD

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL STE 219
SAN DIEGO CA
92130-3084
US

IV. Provider business mailing address

3880 MURPHY CANYON RD STE 200
SAN DIEGO CA
92123-4411
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-1011
  • Fax: 858-793-1035
Mailing address:
  • Phone: 858-636-4300
  • Fax: 858-636-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC167860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: