Provider Demographics
NPI:1619986437
Name:KIM, JEONG H (MD)
Entity Type:Individual
Prefix:
First Name:JEONG
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 1:587 MOANIALA ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-2571
Mailing Address - Country:US
Mailing Address - Phone:808-489-9479
Mailing Address - Fax:808-888-0956
Practice Address - Street 1:1401 S BERETANIA ST STE 320
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1872
Practice Address - Country:US
Practice Address - Phone:808-888-0967
Practice Address - Fax:808-888-0956
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAFE73901207RG0100X
WI54642207RG0100X
WAMD00047928207RG0100X
HIMD-16105207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
9275116OtherAETNA
WA227617OtherLABOR & INDUSTRIES
9185KIOtherREGENCE BLUE SHIELD
WA8501496Medicaid
WA227617OtherLABOR & INDUSTRIES
9185KIOtherREGENCE BLUE SHIELD
WA8501496Medicaid
WABK8848523OtherDEA - MILITARY ONLY.
G8870814Medicare PIN
G8870813Medicare PIN