Provider Demographics
NPI:1780004010
Name:JOHN KIM, M.D.A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:JOHN KIM, M.D.A PROFESSIONAL CORPORATION
Other - Org Name:ANGELES HEALTHCARE WC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-402-7622
Mailing Address - Street 1:11911 ARTESIA BLVD
Mailing Address - Street 2:SUIT #101
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90701-4065
Mailing Address - Country:US
Mailing Address - Phone:562-402-7622
Mailing Address - Fax:
Practice Address - Street 1:1433 W MERCED AVE
Practice Address - Street 2:SUIT #311
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3402
Practice Address - Country:US
Practice Address - Phone:626-960-3066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE89338Medicare UPIN
CAG66684Medicare PIN