Provider Demographics
NPI:1760640478
Name:KIM, JONGHO (MD)
Entity Type:Individual
Prefix:DR
First Name:JONGHO
Middle Name:
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 1:306 RIVEREDGE RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1938
Mailing Address - Country:US
Mailing Address - Phone:917-882-8208
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST # MC28
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:917-882-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0026366207U00000X
NY290542207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY860279748OtherUNITEDHEALTHCARE