Provider Demographics
NPI:1013100122
Name:KIM-JUDD, JEONG NAM (MD)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:NAM
Last Name:KIM-JUDD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEONG NAM
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 419052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9052
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4449
Practice Address - Street 1:637 DUNN RD STE 180
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1759
Practice Address - Country:US
Practice Address - Phone:314-838-7912
Practice Address - Fax:314-921-6283
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL036128909208000000X
MO2011032430208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508292Medicaid