Provider Demographics
NPI:1023097375
Name:KIM, JOHNNY JONGSUN (MD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:JONGSUN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 LEON GUERRERO DR
Mailing Address - Street 2:1001 BLUE PACIFIC LATTICE CONDO
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6358
Practice Address - Country:US
Practice Address - Phone:508-383-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1759146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant