Provider Demographics
NPI:1679597835
Name:KIM, JIN RIAN (MD)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:RIAN
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:PO BOX 10069
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0069
Mailing Address - Country:US
Mailing Address - Phone:920-835-1100
Mailing Address - Fax:920-835-1099
Practice Address - Street 1:7000 BOULDER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3348
Practice Address - Country:US
Practice Address - Phone:909-862-1191
Practice Address - Fax:909-793-2916
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41996207P00000X
CAC55676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851477913OtherCMH NPI
WI32644100Medicaid
WI11014110Medicaid
HI6655Medicare UPIN
WI00439Medicare PIN
WI030280034Medicare Oscar/Certification
WI1851477913OtherCMH NPI
WI11014110Medicaid