Provider Demographics
NPI:1083685218
Name:KIM, JAE DOO (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:DOO
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 1:6421 SARATOGA BLVD.
Mailing Address - Street 2:BLDG. 106
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-3480
Mailing Address - Country:US
Mailing Address - Phone:361-991-7109
Mailing Address - Fax:361-991-5213
Practice Address - Street 1:6421 SARATOGA BLVD.
Practice Address - Street 2:BLDG. 106
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-3480
Practice Address - Country:US
Practice Address - Phone:361-991-7109
Practice Address - Fax:361-991-5213
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9286174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16685840 01Medicaid
TXH69484Medicare UPIN
TX16685840 01Medicaid