Provider Demographics
NPI:1255657151
Name:KIM, JAMES D (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:D
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 1:7802 W JEFFERSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4138
Mailing Address - Country:US
Mailing Address - Phone:260-305-2822
Mailing Address - Fax:260-305-2829
Practice Address - Street 1:7802 W JEFFERSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4138
Practice Address - Country:US
Practice Address - Phone:260-305-2822
Practice Address - Fax:260-305-2829
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62214-20207W00000X
IN01083315A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300058132Medicaid
KY7100053130Medicaid
IN300058132Medicaid