Provider Demographics
NPI:1861591786
Name:KIM, JEONG H (MD)
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:H
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 1:3814 222ND PL SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4220
Mailing Address - Country:US
Mailing Address - Phone:425-922-7401
Mailing Address - Fax:425-899-5304
Practice Address - Street 1:11812 N CREEK PKWY N STE 202
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-287-5500
Practice Address - Fax:425-287-6440
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0036606207R00000X
WAMD00036606207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1020945Medicaid
G77851Medicare UPIN
WA1020945Medicaid