Provider Demographics
NPI:1164828208
Name:KIM, DONG GUK (DC)
Entity Type:Individual
Prefix:
First Name:DONG GUK
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9275 BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:STE 104
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-3943
Mailing Address - Country:US
Mailing Address - Phone:410-480-0083
Mailing Address - Fax:410-480-0082
Practice Address - Street 1:9275 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:STE 104
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3943
Practice Address - Country:US
Practice Address - Phone:410-480-0083
Practice Address - Fax:410-480-0082
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03894111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor