Provider Demographics
NPI:1225199201
Name:JONG G KIM M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JONG G KIM M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONG
Authorized Official - Middle Name:G
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-860-0606
Mailing Address - Street 1:414 S PROSPECTORS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1615
Mailing Address - Country:US
Mailing Address - Phone:909-860-0606
Mailing Address - Fax:909-860-6161
Practice Address - Street 1:414 S PROSPECTORS RD
Practice Address - Street 2:SUITE B
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1615
Practice Address - Country:US
Practice Address - Phone:909-860-0606
Practice Address - Fax:909-860-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32816174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6169716Medicaid
CA6169716Medicaid