Provider Demographics
NPI:1255307104
Name:KIM, DONG S (MD)
Entity Type:Individual
Prefix:DR
First Name:DONG
Middle Name:S
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 1:489 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093
Mailing Address - Country:US
Mailing Address - Phone:847-410-8442
Mailing Address - Fax:847-410-8443
Practice Address - Street 1:4709 GOLF RD
Practice Address - Street 2:STE 812
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1258
Practice Address - Country:US
Practice Address - Phone:847-410-8442
Practice Address - Fax:847-410-8443
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01622554OtherBS OF ILL
IL036101382Medicaid
K39183Medicare PIN
H24112Medicare UPIN