Provider Demographics
NPI:1255334900
Name:KIM, JONG K (MD)
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:K
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:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-0808
Mailing Address - Country:US
Mailing Address - Phone:301-724-1646
Mailing Address - Fax:301-724-7429
Practice Address - Street 1:952 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1950
Practice Address - Country:US
Practice Address - Phone:301-777-3522
Practice Address - Fax:301-777-1902
Is Sole Proprietor?:No
Enumeration Date:2005-05-25
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD46088174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ2470001OtherGHMSI
PA0015256100019Medicaid
MDJ2490001OtherGHMSI
PA37054OtherHIGHMARK BLUE SHIELD
MDJ2480001OtherGHMSI
P00059981OtherMEDICARE RAILROAD
WV0120562000Medicaid
MDJ2490001OtherGHMSI
E80486Medicare UPIN
P00089235Medicare PIN
P00059981OtherMEDICARE RAILROAD
PA37054OtherHIGHMARK BLUE SHIELD
MD417FMedicare PIN
WV4092943Medicare PIN
P00059981Medicare PIN
WV4092944Medicare PIN