Active NPI
Kenneth Jae Yoon Kim, MD
- Pediatrics Physician
- Fairfax, VA
National Provider Identifier
1124221924
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 0101245549
- Practice address
- 3930 Pender Dr
Suite 330
Fairfax, VA 22030-0985 - Phone
- (703) 246-0022
- Fax
- (703) 246-0080
- NPI assigned
- Jun 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 0101245549 | VA | Primary |
Addresses
Primary practice location
3930 Pender Dr
Suite 330
Fairfax, VA 22030-0985
Mailing address
3930 Pender Dr
Suite 330
Fairfax, VA 22030-0985
Phone (703) 246-0022
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1124221924 | Medicaid | VA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0101245549 | VA | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Kenneth J Kim, M.D., P.C. | Past | Accepting new patients | |
| Hojin Lee MD PC | Pediatrics | Past | Accepting new patients |
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/IBJICA/Endpoint/IBJICA
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
dba Kenneth J Kim Pediatrics
- Primary Care Clinic/Center
- Fairfax, VA
- NPI 1710381660
-
dba Grove Pediatrics & Adolescent Medicine
- Pediatrics Physician
- Fairfax, VA
- NPI 1528981230
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1181260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1415664000000",
"number": "1124221924",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3930 PENDER DR",
"address_2": "SUITE 330",
"city": "FAIRFAX",
"state": "VA",
"postal_code": "220300985",
"telephone_number": "703-246-0022",
"fax_number": "703-246-0080"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3930 PENDER DR",
"address_2": "SUITE 330",
"city": "FAIRFAX",
"state": "VA",
"postal_code": "220300985",
"telephone_number": "703-246-0022",
"fax_number": "703-246-0080"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "KENNETH",
"middle_name": "JAE YOON",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-06-08",
"last_updated": "2014-11-11",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "VA",
"license": "0101245549",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1124221924",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fairfax, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 11, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.