Provider Demographics
NPI:1457679631
Name:KIM, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KIM
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 1:615 S CATALINA AVE APT 218
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 WEST CARSON ST
Practice Address - Street 2:LA COUNTY HARBOR-UCLA MEDICAL CENTER
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90509
Practice Address - Country:US
Practice Address - Phone:310-222-2492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1295382084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program