Basic Information
| Provider Information | |||||||||
| NPI: | 1043954902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IM | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | JIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5295 CAMERON DR APT 408 | ||||||||
| Address2: | |||||||||
| City: | BUENA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906211382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143907600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST # C | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095584000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2022 | ||||||||
| LastUpdateDate: | 04/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | STUDENT | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.