Provider Demographics
NPI:1558112151
Name:KIM, SIWOO
Entity Type:Individual
Prefix:
First Name:SIWOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CABOT RD UNIT 338
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5295
Mailing Address - Country:US
Mailing Address - Phone:443-996-0507
Mailing Address - Fax:
Practice Address - Street 1:5 CABOT RD UNIT 338
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5295
Practice Address - Country:US
Practice Address - Phone:443-996-0507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program