Healthcare Provider Details

I. General information

NPI: 1497785810
Provider Name (Legal Business Name): JANE K KIM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10243 GENETIC CENTER DR
SAN DIEGO CA
92121-6310
US

IV. Provider business mailing address

10243 GENETIC CENTER DR
SAN DIEGO CA
92121-6310
US

V. Phone/Fax

Practice location:
  • Phone: 858-526-6100
  • Fax: 858-526-6126
Mailing address:
  • Phone: 858-526-6100
  • Fax: 858-526-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9078
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number20A9078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: