Healthcare Provider Details

I. General information

NPI: 1306199450
Provider Name (Legal Business Name): SANG IL KIM M.D. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12610 VENTURA BLVD
STUDIO CITY CA
91604-2414
US

IV. Provider business mailing address

12610 VENTURA BLVD
STUDIO CITY CA
91604-2414
US

V. Phone/Fax

Practice location:
  • Phone: 818-505-0053
  • Fax: 818-505-0343
Mailing address:
  • Phone: 818-505-0053
  • Fax: 818-505-0343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC42314
License Number StateCA

VIII. Authorized Official

Name: SANG IL KIM
Title or Position: OWNER
Credential: M.D.
Phone: 818-505-0053