Provider Demographics
NPI:1306822242
Name:KIM, JONGYEOL (MD)
Entity Type:Individual
Prefix:
First Name:JONGYEOL
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 1:3601 4TH ST # MS 8321
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-4999
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST # MS 8321
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX426532084N0400X
TXP45852084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC806577OtherPARTNERS
NC140KXOtherBCBS
VA10208416Medicaid
SCQ0142AMedicaid
WV3810003890Medicaid
7046747OtherAETNA
NC182868OtherMEDCOST
NC5902240Medicaid
P00301665Medicare PIN
NC211240BMedicare PIN
NC140KXOtherBCBS
SCQ0142AMedicaid