Provider Demographics
NPI:1699752261
Name:JAN, KUNG-MING (MD)
Entity type:Individual
Prefix:DR
First Name:KUNG-MING
Middle Name:
Last Name:JAN
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 1:3050 CORLEAR AVE.
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5180
Mailing Address - Country:US
Mailing Address - Phone:718-601-4800
Mailing Address - Fax:718-601-6102
Practice Address - Street 1:3050 CORLEAR AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5180
Practice Address - Country:US
Practice Address - Phone:718-601-4800
Practice Address - Fax:718-601-6102
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122967207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00592374Medicaid
NY43A201Medicare ID - Type Unspecified
NY00592374Medicaid