Provider Demographics
NPI:1508070145
Name:KIM, JONG MOON (MD)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:MOON
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 1:13223 TORRINGTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035
Mailing Address - Country:US
Mailing Address - Phone:214-577-2831
Mailing Address - Fax:
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:SUITE 1610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088399207P00000X
TXN0167207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2847807Medicaid
TX8BZ579OtherBCBS
OH000000560036OtherANTHEM
TX195454703Medicaid
TXP00802534OtherRAILROAD
TX195454704Medicaid
TX8BZ579OtherBCBS
TXP00802534OtherRAILROAD
TX8L11496Medicare PIN