Basic Information
| Provider Information | |||||||||
| NPI: | 1720321771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JUNG | ||||||||
| MiddleName: | HA | ||||||||
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| OtherLastName: | KIM | ||||||||
| OtherFirstName: | JOANNE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN SQUARE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110102527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 943399 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.