Provider Demographics
NPI:1427064153
Name:KIM, JUNGYOP (MD)
Entity type:Individual
Prefix:
First Name:JUNGYOP
Middle Name:
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 1:5410 MARYLAND WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5064
Mailing Address - Country:US
Mailing Address - Phone:615-377-5667
Mailing Address - Fax:949-567-9827
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:E PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-687-4131
Practice Address - Fax:631-654-7376
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY633AX1OtherNY EMPIRE BCBS
NY02772190Medicaid
NY01986598Medicaid
NY250SL1Medicare PIN
NYH02048Medicare UPIN
NYP00459752Medicare PIN
NY9Y8651Medicare PIN