Provider Demographics
NPI:1376868893
Name:KIM, DOUGLAS T (LAC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:T
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 RUSSELL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3280
Mailing Address - Country:US
Mailing Address - Phone:301-448-7405
Mailing Address - Fax:
Practice Address - Street 1:937 RUSSELL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3280
Practice Address - Country:US
Practice Address - Phone:301-448-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00751171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist