Healthcare Provider Details

I. General information

NPI: 1013595107
Provider Name (Legal Business Name): JAE YOON KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 EL CAMINO REAL
SOUTH SAN FRANCISCO CA
94080-3299
US

IV. Provider business mailing address

1200 EL CAMINO REAL
SOUTH SAN FRANCISCO CA
94080-3299
US

V. Phone/Fax

Practice location:
  • Phone: 650-742-2000
  • Fax:
Mailing address:
  • Phone: 650-742-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36.004128
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.004128
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: