Provider Demographics
NPI:1477742062
Name:KIM, JAE JIN (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:JIN
Last Name:KIM
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:889 BRIDGEPORT AVE
Mailing Address - Street 2:MILFORD WALK-IN MEDICAL CARE CENTER
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3139
Mailing Address - Country:US
Mailing Address - Phone:203-783-9899
Mailing Address - Fax:203-877-9538
Practice Address - Street 1:889 BRIDGEPORT AVE
Practice Address - Street 2:MILFORD WALK-IN MEDICAL CARE CENTER
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3139
Practice Address - Country:US
Practice Address - Phone:203-783-9899
Practice Address - Fax:203-877-9538
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT019395208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT700000177Medicare PIN