Provider Demographics
NPI:1720541741
Name:KIM, HAESEUNG (DO)
Entity Type:Individual
Prefix:
First Name:HAESEUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5148 S COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7102
Mailing Address - Country:US
Mailing Address - Phone:385-218-0808
Mailing Address - Fax:
Practice Address - Street 1:51ST MEDICAL GROUP UNIT 2060
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:95278
Practice Address - Country:US
Practice Address - Phone:385-218-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine