Provider Demographics
NPI:1093987885
Name:KIM, SAM EUN (MD)
Entity Type:Individual
Prefix:
First Name:SAM EUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-337-5411
Mailing Address - Fax:432-561-5014
Practice Address - Street 1:8050 E HIGHWAY 191
Practice Address - Street 2:STE 200
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8613
Practice Address - Country:US
Practice Address - Phone:432-337-5411
Practice Address - Fax:432-561-5014
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0891207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199366903Medicaid
TX199366901Medicaid