Provider Demographics
NPI:1114968336
Name:KIM, ALISA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALISA
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 1:2403 RESEARCH BLVD STE 102
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6233
Mailing Address - Country:US
Mailing Address - Phone:240-232-2020
Mailing Address - Fax:240-232-2016
Practice Address - Street 1:2403 RESEARCH BLVD STE 102
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6233
Practice Address - Country:US
Practice Address - Phone:240-232-2020
Practice Address - Fax:240-232-2016
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61666207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD243875OtherMEDICARE PTAN
MD405809700Medicaid
DC178540YGP3OtherMEDICARE PTAN
MD243873OtherMEDICARE PTAN
MDKR86J708Medicare ID - Type Unspecified
MDI18811Medicare UPIN
MD243875Medicare PIN
MD243873Medicare PIN
DC178540YGP3OtherMEDICARE PTAN