Provider Demographics
NPI:1346773702
Name:KIM, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:3529 SAINT AUGUSTINE LN
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-2434
Mailing Address - Country:US
Mailing Address - Phone:703-963-6924
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST # 124
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:703-963-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA66067276390200000X
NY315597207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program