Provider Demographics
NPI:1497103220
Name:KIM, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 52ND ST
Mailing Address - Street 2:APT B8
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2706
Mailing Address - Country:US
Mailing Address - Phone:630-544-1406
Mailing Address - Fax:
Practice Address - Street 1:101 W 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6474
Practice Address - Country:US
Practice Address - Phone:212-874-3578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN007022213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery