Healthcare Provider Details

I. General information

NPI: 1205123080
Provider Name (Legal Business Name): JONATHAN YOUNGSUK KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 OLD ROAD TO 9 ACRE COR
CONCORD MA
01742-4159
US

IV. Provider business mailing address

133 OLD ROAD TO 9 ACRE COR
CONCORD MA
01742-4159
US

V. Phone/Fax

Practice location:
  • Phone: 978-287-3794
  • Fax:
Mailing address:
  • Phone: 978-287-3794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number258523
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number258523
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: