Provider Demographics
NPI:1639131154
Name:KIM, JIENSUP (MD)
Entity Type:Individual
Prefix:
First Name:JIENSUP
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0021
Mailing Address - Country:US
Mailing Address - Phone:909-370-0300
Mailing Address - Fax:909-370-0303
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7111
Practice Address - Country:US
Practice Address - Phone:909-370-0300
Practice Address - Fax:909-370-0303
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG758062081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37592ZMedicare ID - Type Unspecified
CAZZZ07116ZMedicare PIN
CAG21366Medicare UPIN