Provider Demographics
NPI:1629264726
Name:KIM, KENNETH SU (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SU
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:PO BOX 758963
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8963
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:47100 COMMUNITY PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-1826
Practice Address - Country:US
Practice Address - Phone:703-880-1403
Practice Address - Fax:703-880-1404
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV0829B - C03895Medicare PIN