Provider Demographics
NPI:1225140759
Name:GIN, JEFFREY KIM-WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KIM-WAYNE
Last Name:GIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1906
Mailing Address - Country:US
Mailing Address - Phone:626-332-6234
Mailing Address - Fax:626-331-1264
Practice Address - Street 1:218 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1906
Practice Address - Country:US
Practice Address - Phone:626-332-6234
Practice Address - Fax:626-331-1264
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35797207Q00000X
CAA101609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070010Medicaid
CABW633ZMedicare PIN
CAGR0070010Medicaid