Provider Demographics
NPI:1518956937
Name:KIM, JUNG H (MD)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:H
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 1:300 GEORGE ST
Mailing Address - Street 2:6TH FLOOR PO BOX 9805
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 CEDAR ST
Practice Address - Street 2:LAUDER HALL RM 108
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022526207ZN0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001225269Medicaid
E46523Medicare UPIN
CT001225269Medicaid