Provider Demographics
NPI:1659359263
Name:KIM, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
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 1898
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-8398
Mailing Address - Country:US
Mailing Address - Phone:201-944-7300
Mailing Address - Fax:201-944-7311
Practice Address - Street 1:158 LINWOOD PLZ STE 324-325
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-3761
Practice Address - Country:US
Practice Address - Phone:201-944-7300
Practice Address - Fax:201-944-7311
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06862000207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7954604Medicaid
NJ7954603Medicaid
NJ1891011854OtherTYPE II NPI
NJ196968Medicare PIN