Provider Demographics
NPI:1194169441
Name:KIM, JI HWAN (MD)
Entity type:Individual
Prefix:
First Name:JI
Middle Name:HWAN
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 1:505 W 400 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-1950
Mailing Address - Country:US
Mailing Address - Phone:801-714-3450
Mailing Address - Fax:801-714-3420
Practice Address - Street 1:505 W 400 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-1950
Practice Address - Country:US
Practice Address - Phone:801-714-3450
Practice Address - Fax:801-714-3420
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9845802-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program