Provider Demographics
NPI:1710958848
Name:KIM, JOHN RAPHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAPHAEL
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 1:6119 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-3072
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4946
Practice Address - Street 1:6119 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-3072
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4946
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101426852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300077566OtherMEDICARE RAILROAD
OH0983280Medicaid
IN300039257OtherMEDICARE RAILROAD
IN100376180Medicaid
IN300077566Medicare PIN
OH0983280Medicaid
IN136270UMedicare PIN
IN300039257Medicare PIN
F67328Medicare UPIN