Provider Demographics
NPI:1467607416
Name:KIM, CHOON-MAN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:CHOON-MAN
Middle Name:JOSEPH
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 MULLHERRIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-856-8990
Mailing Address - Fax:601-856-8990
Practice Address - Street 1:1500 EAST WOODROW WILSON DRIVE
Practice Address - Street 2:RADIOLOGY SERVICE, G.V. MONTGOMERY VA MEDICAL CENTER
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1589
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI37542207U00000X
CANO A-305602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2943329Medicaid
MI2943329Medicaid