Healthcare Provider Details

I. General information

NPI: 1376710665
Provider Name (Legal Business Name): HAN JO KIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4823
US

IV. Provider business mailing address

PO BOX 29234
NEW YORK NY
10087-9234
US

V. Phone/Fax

Practice location:
  • Phone: 212-774-2837
  • Fax: 646-797-8428
Mailing address:
  • Phone: 631-329-6925
  • Fax: 631-329-6951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2011003933
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number246398
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: