Provider Demographics
NPI:1124221924
Name:KIM, KENNETH JAE YOON (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JAE YOON
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3930 PENDER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-0985
Mailing Address - Country:US
Mailing Address - Phone:703-246-0022
Mailing Address - Fax:703-246-0080
Practice Address - Street 1:3930 PENDER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:703-246-0022
Practice Address - Fax:703-246-0080
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245549208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1124221924Medicaid