Provider Demographics
NPI:1225057888
Name:KIM, JANICE PARK (MD)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:PARK
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 ARDEN AVE
Mailing Address - Street 2:#435
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1130
Mailing Address - Country:US
Mailing Address - Phone:818-246-4936
Mailing Address - Fax:818-246-4937
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:#435
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1130
Practice Address - Country:US
Practice Address - Phone:818-246-4936
Practice Address - Fax:818-246-4937
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70428207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG70428OtherCA LINCENSE
CABK4882280OtherDEA
WG70428CMedicare PIN