Healthcare Provider Details

I. General information

NPI: 1427064153
Provider Name (Legal Business Name): JUNGYOP KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 01/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL RD
E PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

5410 MARYLAND WAY SUITE 300
BRENTWOOD TN
37027-5064
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-4131
  • Fax: 631-654-7376
Mailing address:
  • Phone: 615-377-5667
  • Fax: 949-567-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number214678
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: