Provider Demographics
NPI:1225242985
Name:KIM, KIUP ALEXANDER (MD, RPVI)
Entity Type:Individual
Prefix:
First Name:KIUP
Middle Name:ALEXANDER
Last Name:KIM
Suffix:
Gender:M
Credentials:MD, RPVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR STE 360
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2677
Mailing Address - Country:US
Mailing Address - Phone:480-788-5621
Mailing Address - Fax:480-779-1277
Practice Address - Street 1:202 E EARLL DR STE 360
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2677
Practice Address - Country:US
Practice Address - Phone:480-788-5621
Practice Address - Fax:480-779-1277
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42708208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1225242985OtherNPI
AZZ139140OtherPTAN
AZ501341Medicaid