Provider Demographics
NPI:1700405651
Name:KIM, EUI TAE (DPM)
Entity Type:Individual
Prefix:
First Name:EUI TAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7753 MILFORD HAVEN DR APT B
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4741
Mailing Address - Country:US
Mailing Address - Phone:703-472-8310
Mailing Address - Fax:
Practice Address - Street 1:5310 N SHERIDAN RD STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2515
Practice Address - Country:US
Practice Address - Phone:773-205-0106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016006022213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist