MEDICARE: CHARLES CHOL BAE 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	207Q00000X	Family Medicine Physician	54481	AZ
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	C-129160	CA
3	207QA0505X	Adult Medicine Physician	C129160	CA

General Provider Information

NPI Number	:	1225564818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES CHOL BAE KIM MD

Provider Business Mailing Address
First Line	:	1200 W MOHAVE RD
Second Line	:
City	:	PARKER
State	:	AZ
Zip	:	85344-6349
Country	:	US
Telephone Number	:	928-669-7380
Fax Number	:

Provider Business Practice Location Address
First Line	:	14642 NEWPORT AVE STE 105
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-6058
Country	:	US
Telephone Number	:	714-831-1112
Fax Number	:	714-486-2309

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

Provider Enumeration Date	:	05/03/2017
Last Update Date	:	10/13/2021

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