Provider Demographics
NPI:1730592171
Name:KIM, JOON SOO (DO)
Entity type:Individual
Prefix:DR
First Name:JOON
Middle Name:SOO
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14502 W MEEKER BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-5282
Mailing Address - Country:US
Mailing Address - Phone:623-524-8814
Mailing Address - Fax:
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-8814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007951207RN0300X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ998131Medicaid