Provider Demographics
NPI:1891797569
Name:KIM, JONG H (MD)
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:H
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 E 80TH PL
Mailing Address - Street 2:STE 100E
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5671
Mailing Address - Country:US
Mailing Address - Phone:219-769-7536
Mailing Address - Fax:219-736-1506
Practice Address - Street 1:200 E 80TH PL
Practice Address - Street 2:STE 100E
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5671
Practice Address - Country:US
Practice Address - Phone:219-769-7536
Practice Address - Fax:219-736-1506
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01036861A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000066817103OtherUNITED HEALTHCARE
IN000000080494OtherANTHEM
AS65769900001OtherCONN GEN
4520196OtherAETNA
00000053287JOtherANTHEM
452016OtherAETNA
IN100200870Medicaid
452016OtherAETNA
IN100200870Medicaid