Provider Demographics
NPI:1962834796
Name:KIM, JAESUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:JAESUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3826
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:505 NE 87TH AVE STE 460
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1965
Practice Address - Country:US
Practice Address - Phone:360-514-7771
Practice Address - Fax:360-514-7769
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK332382084N0400X
WAMD610544442084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology