Provider Demographics
NPI:1407892268
Name:KIM, JAI (MD)
Entity Type:Individual
Prefix:DR
First Name:JAI
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 1:4524 N MARYVALE PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85031-1732
Mailing Address - Country:US
Mailing Address - Phone:623-846-3186
Mailing Address - Fax:623-846-3757
Practice Address - Street 1:4524 N MARYVALE PKWY STE 220
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031
Practice Address - Country:US
Practice Address - Phone:238-463-1866
Practice Address - Fax:623-846-3757
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233212207Q00000X
AZ52931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02613789Medicaid
I12231Medicare UPIN
NY02613789Medicaid
NY1019P1Medicare PIN
NYRB7792Medicare PIN