Provider Demographics
NPI:1275506560
Name:KIM, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
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 1:711 CANTON RD NE STE 300
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8949
Mailing Address - Country:US
Mailing Address - Phone:678-741-5000
Mailing Address - Fax:678-819-4280
Practice Address - Street 1:118 MILL ST STE 110
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188
Practice Address - Country:US
Practice Address - Phone:678-741-5000
Practice Address - Fax:770-517-5004
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056117174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA247569424BMedicaid
10BDHJLMedicare ID - Type Unspecified
I35805Medicare UPIN