Provider Demographics
NPI:1679787055
Name:KIM, CHARLES CHANG HEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CHANG HEE
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHANG HEE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7500
Practice Address - Fax:651-254-7557
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56188207W00000X, 207W00000X
UT6940151-1205207W00000X
PAMD430964207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2792385Medicaid
WV3810009247Medicaid
PA1019196800001Medicaid
WV3810009247Medicaid