Provider Demographics
NPI:1225079486
Name:KIM, LYNDON (MD)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 WALNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-7000
Practice Address - Fax:215-503-7007
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234593207RH0003X
PAMD439207207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102470466Medicaid
MD402368400Medicaid
NJ0239674Medicaid
MA000530601Medicare PIN
PA184918Medicare PIN
PA102470466Medicaid