Provider Demographics
NPI:1063584696
Name:KIM, JUNG SOON (MD)
Entity type:Individual
Prefix:
First Name:JUNG
Middle Name:SOON
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JEONG
Other - Middle Name:S
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:15 VILLAGE OAKS LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77055-6535
Mailing Address - Country:US
Mailing Address - Phone:713-647-7844
Mailing Address - Fax:
Practice Address - Street 1:6500 NORTH FWY
Practice Address - Street 2:SUITE 116
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77076-2953
Practice Address - Country:US
Practice Address - Phone:713-697-0041
Practice Address - Fax:713-697-6199
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112067702Medicaid
TX112067701Medicaid