Provider Demographics
NPI:1669472098
Name:KIM, P JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:P JOHN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PYOUNG JOHN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:18635 NW US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-8708
Mailing Address - Country:US
Mailing Address - Phone:386-454-2724
Mailing Address - Fax:386-454-2899
Practice Address - Street 1:18635 NW US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-8708
Practice Address - Country:US
Practice Address - Phone:386-454-2724
Practice Address - Fax:386-454-2899
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044632700Medicaid
080010562OtherRAILROAD MEDICARE
FL21008Medicare PIN
FL044632700Medicaid