Healthcare Provider Details

I. General information

NPI: 1003011677
Provider Name (Legal Business Name): JI YEON KIM MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11668 SHERMAN WAY ADMIN
NORTH HOLLYWOOD CA
91605-5831
US

IV. Provider business mailing address

11668 SHERMAN WAY ADMIN
NORTH HOLLYWOOD CA
91605-5831
US

V. Phone/Fax

Practice location:
  • Phone: 818-503-6710
  • Fax:
Mailing address:
  • Phone: 818-503-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberA122377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: