Provider Demographics
NPI:1134511462
Name:P JOHN KIM MD
Entity Type:Organization
Organization Name:P JOHN KIM MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:P JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-454-2724
Mailing Address - Street 1:18635 NW US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-8708
Mailing Address - Country:US
Mailing Address - Phone:386-454-2724
Mailing Address - Fax:386-454-2899
Practice Address - Street 1:18635 NW US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-8708
Practice Address - Country:US
Practice Address - Phone:386-454-2724
Practice Address - Fax:386-454-2899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044632700Medicaid
FLE49343Medicare UPIN
FL21008Medicare PIN