Provider Demographics
NPI:1497724173
Name:KIM, JOO Y (MD)
Entity Type:Individual
Prefix:
First Name:JOO
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT - 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8374
Mailing Address - Fax:
Practice Address - Street 1:485 ARSENAL ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-5091
Practice Address - Country:US
Practice Address - Phone:617-972-5200
Practice Address - Fax:617-972-5512
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA213300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA213300OtherTUFTS
MA694838OtherHARVARD PILGRIM
MAJ25579OtherBLUE CROSS
MA2013410Medicaid
MAH69265Medicare UPIN
MAA34595Medicare PIN