Provider Demographics
NPI:1639132681
Name:KIM, JOHN JUNGKYUM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JUNGKYUM
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:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-215-3063
Mailing Address - Fax:804-968-1803
Practice Address - Street 1:8644 SUDLEY RD
Practice Address - Street 2:SUITE 308
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4425
Practice Address - Country:US
Practice Address - Phone:703-369-9070
Practice Address - Fax:703-369-9240
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236363207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
008321P95Medicare ID - Type Unspecified
I39104Medicare UPIN