Provider Demographics
NPI:1265449961
Name:KIM, JONG GU (MD)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:GU
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONG
Other - Middle Name:GU
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD PMA INC
Mailing Address - Street 1:2221 EAST PROSPECT
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004
Mailing Address - Country:US
Mailing Address - Phone:440-997-5781
Mailing Address - Fax:440-997-5725
Practice Address - Street 1:2221 EAST PROSPECT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004
Practice Address - Country:US
Practice Address - Phone:440-997-5781
Practice Address - Fax:440-997-5725
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35365207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0217661Medicaid
A74445Medicare UPIN
KI0383761Medicare ID - Type Unspecified