Healthcare Provider Details

I. General information

NPI: 1336411610
Provider Name (Legal Business Name): JUN DONG KIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CHICAGO AVE STE F
EAST CHICAGO IN
46312-3261
US

IV. Provider business mailing address

338 LARRY POWER RD
BOURBONNAIS IL
60914-4430
US

V. Phone/Fax

Practice location:
  • Phone: 219-392-7016
  • Fax: 219-397-6904
Mailing address:
  • Phone: 815-935-4651
  • Fax: 815-935-2970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036136056
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number02004986A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: