Provider Demographics
NPI:1366441875
Name:KIM, WON YANG (MD)
Entity Type:Individual
Prefix:DR
First Name:WON
Middle Name:YANG
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:920 WEST ST
Mailing Address - Street 2:STE 218
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-2763
Mailing Address - Country:US
Mailing Address - Phone:815-223-6443
Mailing Address - Fax:815-223-7019
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:SUITE 218
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-2763
Practice Address - Country:US
Practice Address - Phone:815-223-6443
Practice Address - Fax:815-223-7019
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057302207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057302Medicaid
IL110079916OtherRR MEDICARE PTAN
ILD09782Medicare UPIN
IL110079916OtherRR MEDICARE PTAN
IL5005262OtherBLUE SHIELD OF ILLINOIS
IL211691Medicare PIN