Provider Demographics
NPI:1013971027
Name:KIM, PAUL JEONG (DPM)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEONG
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418283
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8283
Mailing Address - Country:US
Mailing Address - Phone:703-558-1544
Mailing Address - Fax:
Practice Address - Street 1:1801 INWOOD ROAD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-2113
Practice Address - Country:US
Practice Address - Phone:214-645-3101
Practice Address - Fax:214-645-3105
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2359213ES0103X
AZ0636213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ952699Medicaid
AZZ135393Medicare PIN
AZ952699Medicaid