Provider Demographics
NPI:1679652317
Name:KIM, JOHN HYUNG SUP (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HYUNG SUP
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 1:847 TICONDEROGA DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-2250
Mailing Address - Country:US
Mailing Address - Phone:408-636-3104
Mailing Address - Fax:
Practice Address - Street 1:33255 9TH ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-2137
Practice Address - Country:US
Practice Address - Phone:510-471-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81600207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G816000Medicaid
00G816000Medicare ID - Type Unspecified
CA00G816000Medicaid
ZZZ14503ZMedicare PIN