Provider Demographics
NPI:1437338605
Name:KIM, LORI CRYSTAL (MD)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:CRYSTAL
Last Name:KIM
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 1:820 LAS GALLINAS AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3410
Mailing Address - Country:US
Mailing Address - Phone:415-446-2500
Mailing Address - Fax:
Practice Address - Street 1:820 LAS GALLINAS AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3410
Practice Address - Country:US
Practice Address - Phone:415-446-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109816207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09164OtherBCBS
FL280072100Medicaid