Provider Demographics
NPI:1073951190
Name:KIM, MICHAEL JAE BUM (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAE BUM
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9353 FAIRWAY VIEW PL STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0972
Mailing Address - Country:US
Mailing Address - Phone:909-858-2772
Mailing Address - Fax:909-300-6324
Practice Address - Street 1:9353 FAIRWAY VIEW PL STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0972
Practice Address - Country:US
Practice Address - Phone:909-858-2772
Practice Address - Fax:909-300-6324
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002476213ES0103X
CAE5294213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery