=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366029035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN DAEJUN KIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2021
-----------------------------------------------------
Last Update Date | 08/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 SW ARCHER RD
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32608-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-376-1611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6577 SW 77TH DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32608-0136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-522-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME165923
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------