Provider Demographics
NPI:1417100207
Name:KIM, YOUNG HO (MD)
Entity Type:Individual
Prefix:
First Name:YOUNG HO
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 1:1901 S UNION AVE STE B7011
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1807
Mailing Address - Country:US
Mailing Address - Phone:253-627-5755
Mailing Address - Fax:253-627-7385
Practice Address - Street 1:1901 S UNION AVE STE B7011
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1807
Practice Address - Country:US
Practice Address - Phone:253-627-5755
Practice Address - Fax:253-627-7385
Is Sole Proprietor?:No
Enumeration Date:2008-10-24
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2008-0737207R00000X
NM101645666390200000X
WAMD60744505207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60744505OtherMEDICAL LICENSE