MEDICARE: DR. IVAN KIM MD, MA

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
2	207L00000X	Anesthesiology Physician	A195501	CA

General Provider Information

NPI Number	:	1477132173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN KIM MD, MA

Provider Business Mailing Address
First Line	:	26520 CACTUS AVE
Second Line	:	DEPARTMENT OF ANESTHESIOLOGY
City	:	MORENO VALLEY
State	:	CA
Zip	:	92555
Country	:	US
Telephone Number	:	951-486-5293
Fax Number	:

Provider Business Practice Location Address
First Line	:	11234 ANDERSON ST
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-2804
Country	:	US
Telephone Number	:	909-558-4015
Fax Number	:

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

Provider Enumeration Date	:	04/08/2021
Last Update Date	:	06/01/2026

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