Provider Demographics
NPI:1831152867
Name:KIM, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:2500 LEMOINE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6232
Mailing Address - Country:US
Mailing Address - Phone:201-461-8110
Mailing Address - Fax:201-461-3614
Practice Address - Street 1:2500 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6232
Practice Address - Country:US
Practice Address - Phone:201-461-8110
Practice Address - Fax:201-461-3614
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA38785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ130940Medicare PIN
NJ130940Medicare ID - Type Unspecified