Basic Information
| Provider Information | |||||||||
| NPI: | 1710958848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RAPHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6119 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468043072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324946 | ||||||||
| Practice Location | |||||||||
| Address1: | 6119 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468043072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604321568 | ||||||||
| FaxNumber: | 2604324946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 10142685 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300077566 | 01 | IN | MEDICARE RAILROAD | OTHER | 0983280 | 05 | OH | MEDICAID | 300039257 | 01 | IN | MEDICARE RAILROAD | OTHER | 100376180 | 05 | IN | MEDICAID |