Healthcare Provider Details

I. General information

NPI: 1639616410
Provider Name (Legal Business Name): JEANNIE KIM MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S ORANGE AVE
EL CAJON CA
92020-7521
US

IV. Provider business mailing address

PO BOX 511419
LOS ANGELES CA
90051-7974
US

V. Phone/Fax

Practice location:
  • Phone: 888-657-1576
  • Fax:
Mailing address:
  • Phone: 866-284-2771
  • Fax: 800-334-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA72965
License Number StateCA

VIII. Authorized Official

Name: JEANNIE G KIM
Title or Position: PRESIDENT
Credential: MD
Phone: 858-699-0669