Provider Demographics
NPI:1558311092
Name:KIM, JEFFREY D (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4247 W RIDGE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1746
Mailing Address - Country:US
Mailing Address - Phone:814-838-2468
Mailing Address - Fax:814-835-2599
Practice Address - Street 1:4247 W RIDGE RD STE 105
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1746
Practice Address - Country:US
Practice Address - Phone:814-838-2468
Practice Address - Fax:814-835-2599
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS013025207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine