Provider Demographics
NPI:1689651226
Name:KMJAN, LLC
Entity Type:Organization
Organization Name:KMJAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KUNG-MING
Authorized Official - Middle Name:
Authorized Official - Last Name:JAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-543-1877
Mailing Address - Street 1:3656 JOHNSON AVE
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:RIVERDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1609
Mailing Address - Country:US
Mailing Address - Phone:718-543-1877
Mailing Address - Fax:718-543-6677
Practice Address - Street 1:3765 RIVERDALE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:RIVERDALE
Practice Address - State:NY
Practice Address - Zip Code:10463-1845
Practice Address - Country:US
Practice Address - Phone:718-601-4800
Practice Address - Fax:718-601-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122967207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00592374Medicaid
NY43A202Medicare ID - Type Unspecified
NY00592374Medicaid