Provider Demographics
NPI:1609940113
Name:KIM, DAVID DAEWHAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DAEWHAN
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:2799 WEST GRAND BOULEVARD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-2436
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BOULEVARD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066691208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
250Q260840OtherBLUE CROSS-BLUE CROSS
DK066691OtherCHAMPUS-CHAMPUS
DK066691OtherCOMMERCIAL-COMMERCIAL NUMBER
MI447344610Medicaid