Healthcare Provider Details

I. General information

NPI: 1275707846
Provider Name (Legal Business Name): JASON MICHAEL KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPARTMENT OF UROLOGY HSC 9 STONY BROOK UNIVERSITY MEDICAL CENTER
STONY BROOK NY
11794-7148
US

IV. Provider business mailing address

DEPARTMENT OF UROLOGY HSC 9 STONY BROOK UNIVERSITY MEDICAL CENTER
STONY BROOK NY
11794-7148
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-1916
  • Fax: 631-444-7620
Mailing address:
  • Phone: 631-444-1916
  • Fax: 631-444-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number261117
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number261117
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: