Provider Demographics
NPI:1447383401
Name:KIM, JEONG UN (PH D)
Entity Type:Individual
Prefix:DR
First Name:JEONG
Middle Name:UN
Last Name:KIM
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 S ALEXANDRIA AVE
Mailing Address - Street 2:APT 225
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2860
Mailing Address - Country:US
Mailing Address - Phone:213-389-3153
Mailing Address - Fax:213-389-3153
Practice Address - Street 1:545 S ALVARADO ST
Practice Address - Street 2:#B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2903
Practice Address - Country:US
Practice Address - Phone:213-483-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9090171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6134936OtherMEDICAL PIN