Basic Information
Provider Information
NPI: 1003011677
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KIM
FirstName: JI YEON
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MD, MPH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11668 SHERMAN WAY
Address2: ADMIN
City: NORTH HOLLYWOOD
State: CA
PostalCode: 916055831
CountryCode: US
TelephoneNumber: 8185036710
FaxNumber:  
Practice Location
Address1: 11668 SHERMAN WAY
Address2: ADMIN
City: NORTH HOLLYWOOD
State: CA
PostalCode: 916055831
CountryCode: US
TelephoneNumber: 8185036710
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/15/2007
LastUpdateDate: 04/29/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207ZP0105XA122377CAY Allopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine

No ID Information.


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