Provider Demographics
NPI:1033188289
Name:KIM, KITAE (MD)
Entity Type:Individual
Prefix:
First Name:KITAE
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 1:2657 WINDMILL PKWY # 685
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-3384
Mailing Address - Country:US
Mailing Address - Phone:702-629-3771
Mailing Address - Fax:702-438-6666
Practice Address - Street 1:3061 S MARYLAND PKWY STE 104
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-6226
Practice Address - Country:US
Practice Address - Phone:702-629-3771
Practice Address - Fax:702-438-6666
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV115672086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507450Medicaid
AZ974445Medicaid
CAXPY205014Medicaid
I22508Medicare UPIN
NV100507450Medicaid
P00363719Medicare PIN