Provider Demographics
NPI:1689798472
Name:KIM, JUNG S (MD)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 BLUESPRING LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2614
Mailing Address - Country:US
Mailing Address - Phone:314-432-0643
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:C-30
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-567-7765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7E16261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE 08064Medicare UPIN