Provider Demographics
NPI:1275635310
Name:KIM, INGON
Entity Type:Individual
Prefix:
First Name:INGON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:INGON
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5135 ALDINE MAIL ROUTE STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77039-3851
Mailing Address - Country:US
Mailing Address - Phone:281-219-0427
Mailing Address - Fax:281-219-0440
Practice Address - Street 1:5135 ALDINE MAIL RT #100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77039
Practice Address - Country:US
Practice Address - Phone:281-219-0426
Practice Address - Fax:281-219-0440
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133464102Medicaid
C17867Medicare UPIN
TX133464102Medicaid