Provider Demographics
NPI:1003507633
Name:KIM, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 VISTA CAMPANA S UNIT 42
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-8233
Mailing Address - Country:US
Mailing Address - Phone:858-925-3064
Mailing Address - Fax:
Practice Address - Street 1:3760 VISTA CAMPANA S UNIT 42
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-8233
Practice Address - Country:US
Practice Address - Phone:858-925-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program