Provider Demographics
NPI:1962643379
Name:KIM, JONATHAN KILTAI (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KILTAI
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 1:5225 CANYON CREST DR
Mailing Address - Street 2:BLDG. 100, SUITE 103
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5225 CANYON CREST DR
Practice Address - Street 2:BLDG. 100, SUITE 103
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6301
Practice Address - Country:US
Practice Address - Phone:951-248-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-13
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1385662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN