Provider Demographics
NPI:1114235942
Name:SUSAN KIM MD PS
Entity Type:Organization
Organization Name:SUSAN KIM MD PS
Other - Org Name:LAKE WASHINGTON DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-821-6363
Mailing Address - Street 1:10117 NE 58TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98033-7450
Mailing Address - Country:US
Mailing Address - Phone:425-821-6363
Mailing Address - Fax:425-821-4804
Practice Address - Street 1:10117 NE 58TH ST STE 200
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-7450
Practice Address - Country:US
Practice Address - Phone:425-821-6363
Practice Address - Fax:425-821-4804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037239207N00000X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8918028Medicare PIN