Provider Demographics
NPI:1336411610
Name:KIM, JUN DONG (DO)
Entity type:Individual
Prefix:DR
First Name:JUN
Middle Name:DONG
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 LARRY POWER RD
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4430
Mailing Address - Country:US
Mailing Address - Phone:815-935-4651
Mailing Address - Fax:815-935-2970
Practice Address - Street 1:100 W CHICAGO AVE STE F
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3261
Practice Address - Country:US
Practice Address - Phone:219-392-7016
Practice Address - Fax:219-397-6904
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136056207V00000X
IN02004986A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136056Medicaid
ILF400156256Medicare PIN