Healthcare Provider Details

I. General information

NPI: 1760411946
Provider Name (Legal Business Name): PETER KIM MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 ROADRUNNER WAY
SIMI VALLEY CA
93065-1210
US

IV. Provider business mailing address

1195 ROADRUNNER WAY
SIMI VALLEY CA
93065-0000
US

V. Phone/Fax

Practice location:
  • Phone: 805-579-8892
  • Fax: 805-579-8951
Mailing address:
  • Phone: 805-579-8892
  • Fax: 805-579-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberA67819
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA67819
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA67819
License Number StateCA

VIII. Authorized Official

Name: DR. PETER K KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-579-8892