Provider Demographics
NPI:1396769519
Name:KIM, JAE S (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JAE
Other - Middle Name:SUK
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5840 W COLONIAL DR
Mailing Address - Street 2:STE 1
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-7558
Mailing Address - Country:US
Mailing Address - Phone:407-767-8554
Mailing Address - Fax:407-767-9121
Practice Address - Street 1:5840 W COLONIAL DR
Practice Address - Street 2:STE 1
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-7558
Practice Address - Country:US
Practice Address - Phone:407-767-8554
Practice Address - Fax:407-767-9121
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041878207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067741800Medicaid
FLD62537Medicare UPIN
FL067741800Medicaid