MEDICARE: DR. JAE Y KIM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207YS0123X	Facial Plastic Surgery Physician	0101259733	VA
2	207Y00000X	Otolaryngology Physician	0101259733	VA

General Provider Information

NPI Number	:	1609168327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAE Y KIM M.D.

Provider Business Mailing Address
First Line	:	2200 WILSON BLVD STE 102-219
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-3397
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 WILSON BLVD STE 102-219
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-3397
Country	:	US
Telephone Number	:	347-551-1113
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2011
Last Update Date	:	09/03/2024

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