Provider Demographics
NPI:1669480828
Name:KIM, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:331 MELROSE DR
Mailing Address - Street 2:220
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-4405
Mailing Address - Country:US
Mailing Address - Phone:469-828-1903
Mailing Address - Fax:469-374-3851
Practice Address - Street 1:331 MELROSE DR
Practice Address - Street 2:220
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4405
Practice Address - Country:US
Practice Address - Phone:469-828-1903
Practice Address - Fax:469-374-3851
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2728207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040413902Medicaid
TX040413902Medicaid
TXG68504Medicare UPIN