Provider Demographics
NPI:1770788754
Name:ANTHONY KIM MD INC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:ANTHONY KIM MD INC A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEUN-YOUNG
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-388-7190
Mailing Address - Street 1:26732 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 541
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6306
Mailing Address - Country:US
Mailing Address - Phone:949-388-7190
Mailing Address - Fax:949-388-7150
Practice Address - Street 1:26732 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 541
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6306
Practice Address - Country:US
Practice Address - Phone:949-388-7190
Practice Address - Fax:949-388-7150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79340207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21134Medicare PIN
CA5970090001Medicare NSC