Provider Demographics
NPI:1639444904
Name:KIM, DANIEL DAE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:DAE
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9601 BAPTIST HEALTH DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6342
Mailing Address - Country:US
Mailing Address - Phone:201-219-0900
Mailing Address - Fax:
Practice Address - Street 1:9601 BAPTIST HEALTH DR STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6342
Practice Address - Country:US
Practice Address - Phone:201-219-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69149207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI163944904Medicaid
000001463478OtherAMERICAN ACADEMY OF OPHTHALMOLOGY
WI69149OtherWI STATE LICENSE
13928487OtherCAQH
13928487OtherCAQH