Provider Demographics
NPI:1689618654
Name:KIM, CHUNG K (MD)
Entity Type:Individual
Prefix:
First Name:CHUNG
Middle Name:K
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:CHUNG KIEL
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2000 ROOSEVELT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2800
Mailing Address - Country:US
Mailing Address - Phone:219-464-3063
Mailing Address - Fax:219-462-6448
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-464-3063
Practice Address - Fax:219-462-6448
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030918A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084854OtherBLUE CROSS PROVIDER NUMBE
IN000000084854OtherBLUE CROSS PROVIDER NUMBE
IN658290Medicare PIN
IN0190000001Medicare NSC