Basic Information
| Provider Information | |||||||||
| NPI: | 1194388736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 DAWNWOOD | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776329212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403000855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148202361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2019 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.