Provider Demographics
NPI:1376733873
Name:KIM, JASON K (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:K
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4414 LAKE BOONE TRL STE 505
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7521
Mailing Address - Country:US
Mailing Address - Phone:919-784-2300
Mailing Address - Fax:
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-784-2300
Practice Address - Fax:919-784-2301
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2012-02076208600000X, 2086S0129X
NY2526382086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1050075Medicaid