Basic Information
| Provider Information | |||||||||
| NPI: | 1831169606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | LORIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIM | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
| OtherMiddleName: | LORIE VALERA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1700 NORTH WATERMAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNANDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098838611 | ||||||||
| FaxNumber: | 9098815707 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 NORTH WATERMAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNANDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098838611 | ||||||||
| FaxNumber: | 9098861798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A73117 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A731170 | 05 | CA | MEDICAID |