Provider Demographics
NPI:1578527453
Name:KIM, DAI JUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:DAI
Middle Name:JUNG
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 1:2101 FOREST AVE SUITE 126
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1424
Mailing Address - Country:US
Mailing Address - Phone:650-279-2455
Mailing Address - Fax:
Practice Address - Street 1:2101 FOREST AVE STE 126
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1424
Practice Address - Country:US
Practice Address - Phone:650-279-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34120207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA27379Medicare UPIN