Provider Demographics
NPI:1619186053
Name:KIM, PETER JOO (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9500 KANIS RD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6324
Mailing Address - Country:US
Mailing Address - Phone:501-227-9080
Mailing Address - Fax:501-227-0410
Practice Address - Street 1:9500 KANIS RD
Practice Address - Street 2:SUITE 501
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6324
Practice Address - Country:US
Practice Address - Phone:501-227-9080
Practice Address - Fax:501-227-0410
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2012-05-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARE5116208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164967001Medicaid
AR5N883Medicare PIN