Provider Demographics
NPI:1114484797
Name:KIM, MICHAEL Y (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:Y
Last Name: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 1:10099 RIDGEGATE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5532
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-6844
Practice Address - Country:US
Practice Address - Phone:720-874-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-01
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.00074712084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program