Healthcare Provider Details

I. General information

NPI: 1679861694
Provider Name (Legal Business Name): YOUNG MIN KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: YOUNG-MIN KIM M.D.

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E CAROLINE ST J WEST
SAN BERNARDINO CA
92408-3747
US

IV. Provider business mailing address

11175 CAMPUS STREET DEPARTMENT OF PEDIATRICS, COLEMAN PAVILLION
LOMA LINDA CA
92354
US

V. Phone/Fax

Practice location:
  • Phone: 909-835-1810
  • Fax: 909-835-1780
Mailing address:
  • Phone: 909-558-8291
  • Fax: 909-558-0440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2011015241
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberA141523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: