MEDICARE: DR. DOMINIQUE B YANG-KIM D.O.

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	207R00000X	Internal Medicine Physician	XXXX	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15019054	OTHER		CAQH

General Provider Information

NPI Number	:	1225299688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIQUE B YANG-KIM D.O.

Provider Business Mailing Address
First Line	:	9110 FAIRLAND ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-4434
Country	:	US
Telephone Number	:	626-394-1408
Fax Number	:

Provider Business Practice Location Address
First Line	:	5253 PRUE RD STE 315C
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-1758
Country	:	US
Telephone Number	:	210-750-8100
Fax Number	:

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

Provider Enumeration Date	:	06/18/2008
Last Update Date	:	12/01/2020

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