Provider Demographics
NPI:1003991159
Name:KIM, JOHN SHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SHIN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:11911 ARTESIA BLVD
Mailing Address - Street 2:#101
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90701
Mailing Address - Country:US
Mailing Address - Phone:562-402-7622
Mailing Address - Fax:562-402-2452
Practice Address - Street 1:11911 ARTESIA BLVD
Practice Address - Street 2:#101
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90701-4070
Practice Address - Country:US
Practice Address - Phone:562-402-7622
Practice Address - Fax:562-402-2452
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2010-02-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG66684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G666841Medicaid
CA00G666841Medicaid
CAG66684Medicare ID - Type Unspecified