Provider Demographics
NPI:1437715380
Name:KIM, JEREMY S (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-1152
Mailing Address - Country:US
Mailing Address - Phone:608-882-5170
Mailing Address - Fax:608-882-6532
Practice Address - Street 1:10 N WATER ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1152
Practice Address - Country:US
Practice Address - Phone:608-882-5170
Practice Address - Fax:608-882-6532
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI75634-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437715380Medicaid