Healthcare Provider Details

I. General information

NPI: 1780497479
Provider Name (Legal Business Name): JONATHAN KIM PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2025
Last Update Date: 01/28/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12424 WILSHIRE BLVD
LOS ANGELES CA
90025-1052
US

IV. Provider business mailing address

1517 S VAN NESS AVE
LOS ANGELES CA
90019-4632
US

V. Phone/Fax

Practice location:
  • Phone: 310-826-2977
  • Fax:
Mailing address:
  • Phone: 818-983-6778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: