Provider Demographics
NPI:1831105048
Name:KIM, JIN SOO (MD)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:SOO
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 1:320 PRATHER AVENUE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6820
Mailing Address - Country:US
Mailing Address - Phone:716-664-5712
Mailing Address - Fax:716-664-4111
Practice Address - Street 1:320 PRATHER AVENUE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6820
Practice Address - Country:US
Practice Address - Phone:716-664-5712
Practice Address - Fax:716-664-4111
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113507207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00639336Medicaid
000505500001OtherBCBS
B54128Medicare UPIN
NY00639336Medicaid