Healthcare Provider Details

I. General information

NPI: 1376384727
Provider Name (Legal Business Name): JONATHAN D KIM DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 S WALNUT GROVE AVE APT B
SAN GABRIEL CA
91776-1757
US

IV. Provider business mailing address

190 S WALNUT GROVE AVE APT B
SAN GABRIEL CA
91776-1757
US

V. Phone/Fax

Practice location:
  • Phone: 442-599-4470
  • Fax:
Mailing address:
  • Phone: 442-599-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN KIM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: DPM
Phone: 442-599-4470