Provider Demographics
NPI:1679700918
Name:KIM, SO RA (MD)
Entity Type:Individual
Prefix:DR
First Name:SO RA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S MORRISON RD
Mailing Address - Street 2:APT # 99
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4043
Mailing Address - Country:US
Mailing Address - Phone:702-743-0286
Mailing Address - Fax:
Practice Address - Street 1:405 S MORRISON RD
Practice Address - Street 2:APT # 99
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4043
Practice Address - Country:US
Practice Address - Phone:702-743-0286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-13
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014847A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program