Provider Demographics
NPI:1356605836
Name:KIM, JONGJIN (MD)
Entity type:Individual
Prefix:
First Name:JONGJIN
Middle Name:
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 1:145 VERSAILLES CIR APT D
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6933
Mailing Address - Country:US
Mailing Address - Phone:443-862-6573
Mailing Address - Fax:
Practice Address - Street 1:5471 LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1745
Practice Address - Country:US
Practice Address - Phone:714-752-6088
Practice Address - Fax:657-577-9135
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133928207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN/AMedicaid
MDN/AOtherMEDICARE
MDN/AOtherMEDICARE