Provider Demographics
NPI:1508805052
Name:KIM, DAVID D (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
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:PO BOX 102635
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2635
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:4720 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6292
Practice Address - Country:US
Practice Address - Phone:912-354-4800
Practice Address - Fax:912-629-5821
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047336207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000792932HOtherMEDICAID- VIDALIA
GA000792932FOtherMEDICAID - STATESBORO
GA00792932BMedicaid
GA1508805052OtherMEDICARE RAILROAD
SCG47336Medicaid
GA00792932GOtherMEDICAID - SAVANNAH
SCGPA977OtherMEDICAID GRP. SAV
GA511G701032OtherMEDICARE GROUP
782177OtherBLUE CROSS BLUE SHIELD
GA180037407Medicare PIN
GA41ZCDMQMedicare PIN
SCGPA977OtherMEDICAID GRP. SAV
GA1508805052OtherMEDICARE RAILROAD
GA0412940004Medicare NSC
782177OtherBLUE CROSS BLUE SHIELD
GA6150410005Medicare NSC
GA0412940007Medicare NSC
GA0412940001Medicare NSC
GA6150410004Medicare NSC
SCG47336Medicaid