Provider Demographics
NPI:1235662727
Name:KIM, SEAN SEUNGWON (DO)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:SEUNGWON
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 NE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-2011
Mailing Address - Country:US
Mailing Address - Phone:503-408-7010
Mailing Address - Fax:503-408-7035
Practice Address - Street 1:1350 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2011
Practice Address - Country:US
Practice Address - Phone:503-408-7010
Practice Address - Fax:503-408-7035
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101025691207Q00000X
ORDO207145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty