Provider Demographics
NPI:1306183835
Name:JIENSUP KIM MD A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JIENSUP KIM MD A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JIENSUP
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-370-0300
Mailing Address - Street 1:900 E WASHINGTON ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4120
Mailing Address - Country:US
Mailing Address - Phone:909-370-0300
Mailing Address - Fax:909-370-0303
Practice Address - Street 1:900 E WASHINGTON ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4120
Practice Address - Country:US
Practice Address - Phone:909-370-0300
Practice Address - Fax:909-370-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty