Healthcare Provider Details

I. General information

NPI: 1255402012
Provider Name (Legal Business Name): JENNY MIYON KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 CHILDRENS WAY 2-WEST
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3860 CALLE FORTUNADA SUITE 210
SAN DIEGO CA
92123-4800
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5811
  • Fax:
Mailing address:
  • Phone: 858-309-6303
  • Fax: 858-309-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA80257
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberA80257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: