Provider Demographics
NPI:1053340687
Name:KIM, PETER CHANG (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:CHANG
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4482 BARRANCA PKWY
Mailing Address - Street 2:STE 228
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-1738
Mailing Address - Country:US
Mailing Address - Phone:949-379-3080
Mailing Address - Fax:949-379-3020
Practice Address - Street 1:4482 BARRANCA PKWY STE 228
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-1738
Practice Address - Country:US
Practice Address - Phone:949-379-3080
Practice Address - Fax:949-379-3020
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4027213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E40272Medicaid
CA000E40270OtherBLUE SHIELD
CA1316930001OtherDNERC REG O
CA000E40270OtherBLUE SHIELD
U64075Medicare UPIN