Provider Demographics
NPI:1699030163
Name:KIM, MI KYUNG (DPM)
Entity Type:Individual
Prefix:
First Name:MI
Middle Name:KYUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 ATKINSON RD STE D200
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7991
Mailing Address - Country:US
Mailing Address - Phone:678-731-7545
Mailing Address - Fax:678-731-7546
Practice Address - Street 1:1790 ATKINSON RD STE D200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7991
Practice Address - Country:US
Practice Address - Phone:678-731-7545
Practice Address - Fax:678-731-7546
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001300213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I483145Medicare UPIN