Basic Information
| Provider Information | |||||||||
| NPI: | 1639616410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEANNIE KIM MD A PROFESSIONAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 511419 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900517974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662842771 | ||||||||
| FaxNumber: | 8003341041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S ORANGE AVE | ||||||||
| Address2: | |||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920207521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886571576 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2017 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | JEANNIE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8586990669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | A72965 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.