Provider Demographics
NPI:1124009303
Name:KIM, KYONG HO (DO)
Entity Type:Individual
Prefix:
First Name:KYONG
Middle Name:HO
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 39324
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98496-3324
Mailing Address - Country:US
Mailing Address - Phone:253-983-9390
Mailing Address - Fax:253-983-0066
Practice Address - Street 1:11306 BRIDGEPORT WAY SW
Practice Address - Street 2:SUITE D
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3037
Practice Address - Country:US
Practice Address - Phone:253-983-9390
Practice Address - Fax:253-983-0066
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001595207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1002900Medicaid
WAG8800009Medicare UPIN
WAAB09841Medicare ID - Type Unspecified