Provider Demographics
NPI:1508050220
Name:KIM, JOHN JIN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JIN
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 1:1900 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4614
Mailing Address - Country:US
Mailing Address - Phone:909-825-3425
Mailing Address - Fax:909-825-6991
Practice Address - Street 1:1900 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4614
Practice Address - Country:US
Practice Address - Phone:909-825-3425
Practice Address - Fax:909-825-6991
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111549207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508050220Medicaid
CADE662XMedicare PIN