Healthcare Provider Details

I. General information

NPI: 1124099213
Provider Name (Legal Business Name): JAE KOUL KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4729 E SUNRISE DR # 315
TUCSON AZ
85718-4534
US

IV. Provider business mailing address

4729 E SUNRISE DR # 315
TUCSON AZ
85718-4534
US

V. Phone/Fax

Practice location:
  • Phone: 520-429-2023
  • Fax:
Mailing address:
  • Phone: 520-429-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number32890
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number32890
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number32890
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: