Basic Information
| Provider Information | |||||||||
| NPI: | 1427064153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JUNGYOP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775667 | ||||||||
| FaxNumber: | 9495679827 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | E PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117724870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316874131 | ||||||||
| FaxNumber: | 6316547376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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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 | 207R00000X | 214678 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 633AX1 | 01 | NY | NY EMPIRE BCBS | OTHER | 02772190 | 05 | NY | MEDICAID | 01986598 | 05 | NY | MEDICAID |