Provider Demographics
NPI:1013595107
Name:KIM, JAE YOON
Entity Type:Individual
Prefix:
First Name:JAE YOON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-713-1779
Mailing Address - Fax:513-854-9921
Practice Address - Street 1:350 W WILSON BRIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2591
Practice Address - Country:US
Practice Address - Phone:614-895-8747
Practice Address - Fax:614-895-8810
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.004128213E00000X, 213ES0103X
261QP1100X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program