Provider Demographics
NPI:1114423183
Name:KIM, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MANNING DR # 7594
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-4221
Mailing Address - Country:US
Mailing Address - Phone:919-966-6442
Mailing Address - Fax:919-966-3049
Practice Address - Street 1:170 MANNING DR CB# 7594
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-2153
Practice Address - Country:US
Practice Address - Phone:919-966-6442
Practice Address - Fax:919-966-3049
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-01063207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program