Provider Demographics
NPI:1740223551
Name:KIM, YOUNG DAE (MD)
Entity Type:Individual
Prefix:
First Name:YOUNG DAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YOUNG DAE
Other - Middle Name:
Other - Last Name:YOUNGDAE KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:962-883-7961
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:2220 RIVERSIDE AVE S
Practice Address - Street 2:MAIL STOP 31700A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1321
Practice Address - Country:US
Practice Address - Phone:617-371-1600
Practice Address - Fax:612-371-1732
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36587207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F68720Medicare UPIN