Provider Demographics
NPI:1104220102
Name:KIM, JONATHAN (DPM)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74000 COUNTRY CLUB DR STE E4
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-1678
Mailing Address - Country:US
Mailing Address - Phone:760-848-8231
Mailing Address - Fax:
Practice Address - Street 1:81709 DR CARREON BLVD STE D3
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5578
Practice Address - Country:US
Practice Address - Phone:760-863-0070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE5392213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist