Provider Demographics
NPI:1467503920
Name:KIM, JIN KOO (MD)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:KOO
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6622 N 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:2580 HIGHWAY 95 STE 224
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7332
Practice Address - Country:US
Practice Address - Phone:928-763-7722
Practice Address - Fax:928-763-7744
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ41404207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ395430Medicaid
AZ128584Medicare PIN
AZ133095Medicare PIN