Provider Demographics
NPI:1336125798
Name:KIM, NAMOU (MD)
Entity Type:Individual
Prefix:DR
First Name:NAMOU
Middle Name:
Last Name:KIM
Suffix:
Gender:M
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1221 MADISON ST STE 1523
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1342
Practice Address - Country:US
Practice Address - Phone:206-292-6464
Practice Address - Fax:206-292-6498
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60101869207YX0007X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8550915Medicaid
WA1336125798Medicaid
WA298197OtherDEPT OF LABOR & INDUSTRIES
AZP00020654OtherRAILROAD MEDICARE
H83901Medicare UPIN