Provider Demographics
NPI:1588850341
Name:KIM, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
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 1:5006 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6719
Mailing Address - Country:US
Mailing Address - Phone:516-851-7601
Mailing Address - Fax:
Practice Address - Street 1:5006 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6719
Practice Address - Country:US
Practice Address - Phone:516-851-7601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19332183500000X
VA0202210523183500000X
TN40044183500000X
NY040538183500000X
TX58095183500000X
MDU02470171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No183500000XPharmacy Service ProvidersPharmacist