=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083417935
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEOYOUNG KIM MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2025
-----------------------------------------------------
Last Update Date | 03/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 1ST AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-7494
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-423-6262
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7069 OREGON ST
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90621-3624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-808-2313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------