Provider Demographics
NPI:1417183047
Name:KIM, KWANG CHO (MD)
Entity Type:Individual
Prefix:
First Name:KWANG
Middle Name:CHO
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 1:3745 CHARTER PL
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2826
Mailing Address - Country:US
Mailing Address - Phone:734-663-1938
Mailing Address - Fax:
Practice Address - Street 1:3745 CHARTER PL
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2826
Practice Address - Country:US
Practice Address - Phone:734-663-1938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010406932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry