Provider Demographics
NPI:1538456843
Name:KIM, EUGENE T (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:T
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7126 AVALON DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5600
Mailing Address - Country:US
Mailing Address - Phone:919-599-8107
Mailing Address - Fax:770-947-9196
Practice Address - Street 1:7126 AVALON DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-5600
Practice Address - Country:US
Practice Address - Phone:919-599-8107
Practice Address - Fax:770-947-9196
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA87480207Q00000X, 207QG0300X, 207QH0002X
MST2453207Q00000X
PAMT205630207QG0300X
TN53095207QH0002X
VA01012604152081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN