Healthcare Provider Details

I. General information

NPI: 1356839062
Provider Name (Legal Business Name): JAIMY VILLAVICENCIO KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE FL 5
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-646-1550
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number84604-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: