Provider Demographics
NPI:1548218274
Name:KIM, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:JAE-DONG
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:629 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4906
Mailing Address - Country:US
Mailing Address - Phone:909-981-8905
Mailing Address - Fax:909-982-8051
Practice Address - Street 1:629 N 13TH AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4906
Practice Address - Country:US
Practice Address - Phone:909-981-8905
Practice Address - Fax:909-982-8051
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29493174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25790Medicare UPIN
CA00A29493Medicare ID - Type Unspecified
CA4513616Medicaid