Provider Demographics
NPI:1932292109
Name:KIM, JOH W (MD)
Entity Type:Individual
Prefix:MR
First Name:JOH
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10 MAGNOLIA AVENUE
Mailing Address - Street 2:BDG B SUITE I
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-451-4140
Mailing Address - Fax:856-451-3657
Practice Address - Street 1:10 MAGNOLIA AVENUE
Practice Address - Street 2:BLDG B SUITE I
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302
Practice Address - Country:US
Practice Address - Phone:856-451-4140
Practice Address - Fax:856-451-3657
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA02856900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D06127Medicare UPIN