Provider Demographics
NPI:1205907169
Name:KIM, JINCHUL (MD)
Entity type:Individual
Prefix:DR
First Name:JINCHUL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18768 RIDGEBACK CT
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8250
Mailing Address - Country:US
Mailing Address - Phone:571-333-5898
Mailing Address - Fax:
Practice Address - Street 1:18768 RIDGEBACK CT
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8250
Practice Address - Country:US
Practice Address - Phone:571-333-5898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI446562085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21-21-266Medicaid
MI031-031-30-302Medicare ID - Type Unspecified
MI447367Medicare UPIN