Provider Demographics
NPI:1780882258
Name:KIM, JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SIXTH AVE
Mailing Address - Street 2:228
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011
Mailing Address - Country:US
Mailing Address - Phone:718-637-4677
Mailing Address - Fax:
Practice Address - Street 1:1425 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2300
Practice Address - Country:US
Practice Address - Phone:224-783-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244511-1207L00000X
CAA103032207L00000X
IL036158933207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03053129Medicaid