Provider Demographics
NPI:1386685972
Name:KIM, JEAN (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
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:PO BOX 64588
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4588
Mailing Address - Country:US
Mailing Address - Phone:410-550-0460
Mailing Address - Fax:
Practice Address - Street 1:5501 HOPKINS BAYVIEW CIR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-6821
Practice Address - Country:US
Practice Address - Phone:410-550-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47377207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD343781700Medicaid
MDG02367Medicare UPIN
MD343781700Medicaid