Provider Demographics
NPI:1053415281
Name:KIM, SE-UNG SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SE-UNG
Middle Name:SAMUEL
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 N HARBOR BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2626
Mailing Address - Country:US
Mailing Address - Phone:657-243-8300
Mailing Address - Fax:714-278-4286
Practice Address - Street 1:2720 N HARBOR BLVD STE 220
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2626
Practice Address - Country:US
Practice Address - Phone:657-243-8300
Practice Address - Fax:714-278-4286
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44647207VE0102X
KS04-32372207VE0102X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200424060AMedicaid
073F204AMedicare PIN
E60509Medicare UPIN