Provider Demographics
NPI:1619957487
Name:KIM, JOHN MYOUNG KOO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MYOUNG KOO
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 1:1115 WOOSTER RD W
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203
Mailing Address - Country:US
Mailing Address - Phone:330-825-6892
Mailing Address - Fax:330-825-2782
Practice Address - Street 1:1115 WOOSTER RD W
Practice Address - Street 2:
Practice Address - City:BARBERTON
Practice Address - State:OH
Practice Address - Zip Code:44203
Practice Address - Country:US
Practice Address - Phone:330-825-6892
Practice Address - Fax:330-825-2782
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100108207Q00000X, 208D00000X
OH35-100108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0269865Medicaid
778938OtherWORKMAN'S COMP
B77474Medicare UPIN
778938OtherWORKMAN'S COMP