Provider Demographics
NPI:1447240601
Name:KIM, DANIEL D (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
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 1:9307 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2891
Mailing Address - Country:US
Mailing Address - Phone:219-836-2322
Mailing Address - Fax:219-836-2329
Practice Address - Street 1:9307 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2891
Practice Address - Country:US
Practice Address - Phone:219-836-2322
Practice Address - Fax:219-836-2322
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010283652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10025950AMedicaid
IND69786Medicare ID - Type Unspecified
IN10025950AMedicaid