Provider Demographics
NPI:1235495219
Name:KIM, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 JOSEPH SIEWICK DR STE 306
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1764
Mailing Address - Country:US
Mailing Address - Phone:703-391-4520
Mailing Address - Fax:703-391-4521
Practice Address - Street 1:3580 JOSEPH SIEWICK DR STE 306
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1764
Practice Address - Country:US
Practice Address - Phone:703-391-4520
Practice Address - Fax:703-391-4521
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101258997207R00000X
390200000X
VA0101258997207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program