Provider Demographics
NPI:1558530428
Name:JAE M KIM MD
Entity Type:Organization
Organization Name:JAE M KIM MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-536-7534
Mailing Address - Street 1:1433 W MERCED AVE STE 217
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3402
Mailing Address - Country:US
Mailing Address - Phone:626-917-1924
Mailing Address - Fax:626-337-9434
Practice Address - Street 1:1433 W MERCED AVE STE 217
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3402
Practice Address - Country:US
Practice Address - Phone:626-917-1924
Practice Address - Fax:626-337-9434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38835208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383350Medicaid
CAA38835Medicare UPIN