Provider Demographics
NPI:1730676180
Name:KIM, SU HYUN (DPM)
Entity Type:Individual
Prefix:
First Name:SU HYUN
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 1:560 RIVERSIDE DR STE A101
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-4702
Mailing Address - Country:US
Mailing Address - Phone:410-749-0121
Mailing Address - Fax:410-749-6807
Practice Address - Street 1:560 RIVERSIDE DR STE A101
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-4702
Practice Address - Country:US
Practice Address - Phone:410-749-0121
Practice Address - Fax:410-749-6807
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01724213E00000X
NYP10614213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program