Basic Information
| Provider Information | |||||||||
| NPI: | 1891998043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | JYONG WON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | I | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10151 SE SUNNYSIDE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036590880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10151 SE SUNNYSIDE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036590880 | ||||||||
| FaxNumber: | 5035137425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD28418 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01121567 | 01 | OR | RR MEDICARE - PHS | OTHER | 026193 | 05 | OR | MEDICAID |