Basic Information
Provider Information
NPI: 1003803685
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: NG
FirstName: KIM
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 412 COPINSAY CT
Address2:  
City: BAKERSFIELD
State: CA
PostalCode: 933127023
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 6501 TRUXTUN AVE
Address2:  
City: BAKERSFIELD
State: CA
PostalCode: 933090633
CountryCode: US
TelephoneNumber: 6613222206
FaxNumber: 6613277027
Other Information
ProviderEnumerationDate: 09/29/2005
LastUpdateDate: 10/05/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000XA33989CAY Other Service ProvidersSpecialist 

ID Information
IDTypeStateIssuerDescription
A3398901CALICENSEOTHER


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