Provider Demographics
NPI:1548212921
Name:KIM, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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:DEPT LA 21693
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1693
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:36320 INLAND VALLEY DR
Practice Address - Street 2:STE 101
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-7512
Practice Address - Country:US
Practice Address - Phone:951-600-3811
Practice Address - Fax:951-600-4493
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG850232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G850230Medicaid
CA00G850230OtherBCBS
CA00G850230OtherBCBS
H14787Medicare UPIN
CA00G850230Medicare PIN