Provider Demographics
NPI:1689791493
Name:KIM, JIN TAE (MD)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8599 HAVEN AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4849
Mailing Address - Country:US
Mailing Address - Phone:909-620-8180
Mailing Address - Fax:909-919-7288
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:RADIOLOGY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-628-3580
Practice Address - Fax:804-628-3593
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA731782085R0202X
TXM52912085R0202X
VA01012454712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX195889402Medicaid
TX8BC330OtherBCBSTX (BLUE CROSS BLUE SHIELD TEXAS)
TX195889403OtherCSHCN
TX195889403OtherCSHCN
TX8K8155Medicare PIN