Provider Demographics
NPI:1043385529
Name:DACRI-KIM, SANG WON (DO)
Entity Type:Individual
Prefix:DR
First Name:SANG WON
Middle Name:
Last Name:DACRI-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 1:1970 TAMARACK RD.
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055
Mailing Address - Country:US
Mailing Address - Phone:740-344-2452
Mailing Address - Fax:740-522-7305
Practice Address - Street 1:1970 TAMARACK RD.
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055
Practice Address - Country:US
Practice Address - Phone:740-344-2452
Practice Address - Fax:740-522-7305
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006602208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2028577Medicaid
OHP00397004OtherRAILROAD MEDICARE
OHG53636Medicare UPIN
OH0896557Medicare PIN
OH2028577Medicaid
OH0896556Medicare PIN
OH0896551Medicare ID - Type Unspecified