Healthcare Provider Details

I. General information

NPI: 1275799124
Provider Name (Legal Business Name): HAENA KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 08/25/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR STE 280
SAN JOSE CA
95128-1644
US

IV. Provider business mailing address

455 OCONNOR DR STE 280
SAN JOSE CA
95128-1644
US

V. Phone/Fax

Practice location:
  • Phone: 650-507-3601
  • Fax: 650-396-7922
Mailing address:
  • Phone: 650-507-3601
  • Fax: 650-396-7922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA126331
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMD207073
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: