Healthcare Provider Details

I. General information

NPI: 1851612170
Provider Name (Legal Business Name): JIYOON KIM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDDAC-K 121 CSH UNIT 15244
APO AP
96205
US

IV. Provider business mailing address

WRAMC BLDG 2 RM 2G01 6900 GEORGIA AVE, NW
WASHINGTON DC
20307-0001
US

V. Phone/Fax

Practice location:
  • Phone: 101-260-1959
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS019354
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1025529
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: