Provider Demographics
NPI:1124099213
Name:KIM, JAE KOUL (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:KOUL
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 1:4729 E SUNRISE DR # 315
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-4534
Mailing Address - Country:US
Mailing Address - Phone:520-429-2023
Mailing Address - Fax:
Practice Address - Street 1:4729 E SUNRISE DR # 315
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-4534
Practice Address - Country:US
Practice Address - Phone:520-429-2023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ328902085R0202X, 2085U0001X, 2085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1124099213OtherPHYSICIAN INDIVIDUAL NPI
AZCS7943OtherGROUP MEDICARE RAILROAD ID & PTAN
AZZWCBBMOtherGROUP MEDICARE ID
AZ005472OtherGROUP MEDICAID ID
AZ1841261989OtherGROUP NPI
AZ861725Medicaid
AZP00109556OtherMEDICARE RAILROAD
AZZWCBBMOtherGROUP MEDICARE ID
AZZ81206Medicare PIN