MEDICARE: GRACE L. KIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	MT199642	PA
2	207W00000X	Ophthalmology Physician	136906	CA

General Provider Information

NPI Number	:	1003101874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE L. KIM MD

Provider Business Mailing Address
First Line	:	850 HEALTH SCIENCES RD
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92697-4375
Country	:	US
Telephone Number	:	949-824-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	850 HEALTH SCIENCES RD
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92697-4375
Country	:	US
Telephone Number	:	949-824-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2011
Last Update Date	:	12/15/2021

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