Healthcare Provider Details

I. General information

NPI: 1962635854
Provider Name (Legal Business Name): KIM HOANG M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KIM HOANG M.D

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57475 29 PALMS HWY SUITE 101
YUCCA VALLEY CA
92284-2906
US

IV. Provider business mailing address

57475 29 PALMS HWY SUITE 101
YUCCA VALLEY CA
92284-2906
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-9878
  • Fax: 206-309-0387
Mailing address:
  • Phone: 760-365-9878
  • Fax: 206-309-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA104344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: