Provider Demographics
NPI:1326027715
Name:KIM, SHAWN S (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3473 SATELLITE BLVD
Mailing Address - Street 2:SUITE 108 NORTH
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8690
Mailing Address - Country:US
Mailing Address - Phone:770-864-5510
Mailing Address - Fax:770-864-5398
Practice Address - Street 1:3473 SATELLITE BLVD
Practice Address - Street 2:SUITE 108 NORTH
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8690
Practice Address - Country:US
Practice Address - Phone:770-864-5510
Practice Address - Fax:770-864-5398
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2011-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC200401084207R00000X
GA60393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA642674634AMedicaid
NC8113721Medicaid
GA202I112967OtherPTAN
GA202I112967OtherPTAN
NCI15767Medicare UPIN