Provider Demographics
NPI:1053534610
Name:KIM, PETER K (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:K
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 1:1195 ROADRUNNER WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-0000
Mailing Address - Country:US
Mailing Address - Phone:805-579-8892
Mailing Address - Fax:
Practice Address - Street 1:1195 ROADRUNNER WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-0000
Practice Address - Country:US
Practice Address - Phone:805-579-8892
Practice Address - Fax:805-579-8951
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA678192084N0008X, 2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A678190Medicaid
CA609916600OtherUS DEPT OF LABOR ID NUM
CA609916600OtherUS DEPT OF LABOR ID NUM
CAA67819Medicare ID - Type Unspecified
CAH42518Medicare UPIN