Provider Demographics
NPI:1497017289
Name:KIM, KIRSTEN S (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 DUNLAWTON AVE STE 311
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9274
Mailing Address - Country:US
Mailing Address - Phone:386-310-4807
Mailing Address - Fax:386-310-7473
Practice Address - Street 1:870 DUNLAWTON AVE STE 311
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9274
Practice Address - Country:US
Practice Address - Phone:386-310-4807
Practice Address - Fax:863-107-4733
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME117574207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10304000Medicaid