Provider Demographics
NPI:1710339601
Name:KIM, JUNG AH
Entity Type:Individual
Prefix:DR
First Name:JUNG AH
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9455 BALTIMORE NATIONAL PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2812
Mailing Address - Country:US
Mailing Address - Phone:443-535-7575
Mailing Address - Fax:
Practice Address - Street 1:9455 BALTIMORE NATIONAL PIKE STE B
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2812
Practice Address - Country:US
Practice Address - Phone:443-535-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02330171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU02330OtherSTATE LICENSE NUMBER