Provider Demographics
NPI:1174615215
Name:WANG, KIM L (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:WANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 C ST
Mailing Address - Street 2:SUITE #200-E
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-3300
Mailing Address - Country:US
Mailing Address - Phone:916-447-6267
Mailing Address - Fax:916-447-0621
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:SUITE #200-E
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-447-6267
Practice Address - Fax:916-447-0621
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96087174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM269TOtherMEDICARE PTAN
CABM269WOtherMEDICARE PTAN
CABM269UOtherMEDICARE PTAN
CABM269YOtherMEDICARE PTAN
CAA96087Medicaid
CABM269VOtherMEDICARE PTAN
CAA96087OtherMEDICAL LICENSE NUMBER
CABM269SOtherMEDICARE PTAN
CABM269XOtherMEDICARE PTAN
CABM269ZOtherMEDICARE PTAN