Provider Demographics
NPI:1689735953
Name:KIM, JAE M (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:M
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 W MERCED AVE.
Mailing Address - Street 2:SUITE 217
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5058
Mailing Address - Country:US
Mailing Address - Phone:626-917-1924
Mailing Address - Fax:626-337-8434
Practice Address - Street 1:1433 W MERCED AVE.
Practice Address - Street 2:SUITE 217
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5058
Practice Address - Country:US
Practice Address - Phone:626-917-1924
Practice Address - Fax:626-337-8434
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A388350Medicaid
CAA38835Medicare PIN
CAC03987Medicare UPIN