=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376384727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN D KIM DPM PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 S WALNUT GROVE AVE APT B
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 442-599-4470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 S WALNUT GROVE AVE APT B
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 442-599-4470
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | DR. JONATHAN KIM
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 442-599-4470
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------