Provider Demographics
NPI:1235383464
Name:KIM, MYUNG MI (MD)
Entity Type:Individual
Prefix:
First Name:MYUNG
Middle Name:MI
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-355-1813
Mailing Address - Fax:704-355-5980
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-355-1813
Practice Address - Fax:704-355-5980
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1060118208600000X
NC2013-00050208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200931090Medicaid
ININ1060118OtherSTATE LICENSE
SCNC1815Medicaid
NC1235383464Medicaid
NC2013-00050OtherNC LICENSE
NCNCC101AMedicare PIN
IN200931090Medicaid
NC1235383464Medicaid