Provider Demographics
NPI:1073775748
Name:KIM, SOOHYUN (MD)
Entity Type:Individual
Prefix:DR
First Name:SOOHYUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 E HERNDON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3164
Mailing Address - Country:US
Mailing Address - Phone:559-702-1390
Mailing Address - Fax:808-532-2240
Practice Address - Street 1:1191 E HERNDON AVE STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3164
Practice Address - Country:US
Practice Address - Phone:559-702-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-196912086S0129X
CO544432086S0129X
CAA1045312086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01029843Medicaid
CO383003ZLF7Medicare PIN