Healthcare Provider Details

I. General information

NPI: 1386668002
Provider Name (Legal Business Name): JEANNIE G KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 E 4TH ST
NATIONAL CITY CA
91950-2026
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: 619-937-3698
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 NumberA72965
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA72965
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: