Provider Demographics
NPI:1033869268
Name:KIM, JIHAE
Entity type:Individual
Prefix:
First Name:JIHAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 SOUTH CONGRESS AVE
Mailing Address - Street 2:3 SOUTH
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462
Mailing Address - Country:US
Mailing Address - Phone:561-548-1710
Mailing Address - Fax:561-548-1743
Practice Address - Street 1:1075 WHITLOCK AVE SW STE I
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-1996
Practice Address - Country:US
Practice Address - Phone:404-435-0718
Practice Address - Fax:404-941-9543
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD305055213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery