Provider Demographics
NPI:1386668002
Name:KIM, JEANNIE G (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNIE
Middle Name:G
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 511419
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-7974
Mailing Address - Country:US
Mailing Address - Phone:866-284-2771
Mailing Address - Fax:800-334-1041
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:888-657-1576
Practice Address - Fax:619-937-3698
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72965207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A729650Medicaid
A72965Medicare PIN