Provider Demographics
NPI:1639153182
Name:KIM, SEUNG SOO (MD)
Entity Type:Individual
Prefix:
First Name:SEUNG
Middle Name:SOO
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 1:2458 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5406
Mailing Address - Country:US
Mailing Address - Phone:260-424-2195
Mailing Address - Fax:260-422-0077
Practice Address - Street 1:11109 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040258A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100364240Medicaid
INF34646Medicare UPIN
IN132780HMedicare Oscar/Certification