Provider Demographics
NPI:1194388736
Name:KIM, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:800 DAWNWOOD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-9212
Mailing Address - Country:US
Mailing Address - Phone:940-300-0855
Mailing Address - Fax:
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2017
Practice Address - Country:US
Practice Address - Phone:214-820-2361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
TXT5148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program