Provider Demographics
NPI:1699859520
Name:CHANBONPIN, JIMMY (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:
Last Name:CHANBONPIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JIMMY
Other - Middle Name:
Other - Last Name:CHANBONPIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1654 S EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1701
Mailing Address - Country:US
Mailing Address - Phone:626-285-5700
Mailing Address - Fax:626-285-0700
Practice Address - Street 1:1654 S EL MOLINO AVE
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-1701
Practice Address - Country:US
Practice Address - Phone:626-285-5700
Practice Address - Fax:626-285-0700
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA393812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A39381Medicaid
CA1699859520Medicaid
CA00A39381Medicaid