Healthcare Provider Details

I. General information

NPI: 1760744973
Provider Name (Legal Business Name): JENNIFER KIM MD-PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8480
  • Fax: 781-744-3443
Mailing address:
  • Phone: 781-744-8480
  • Fax: 781-744-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number251283
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number261377
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number62559
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: