Provider Demographics
NPI:1740226893
Name:KIM, STEPHEN S (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 NE PARK PLAZA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5895
Mailing Address - Country:US
Mailing Address - Phone:360-254-8025
Mailing Address - Fax:360-254-8618
Practice Address - Street 1:222 NE PARK PLAZA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5895
Practice Address - Country:US
Practice Address - Phone:360-254-8025
Practice Address - Fax:360-254-8618
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA110146504OtherRAILROAD MEDICARE
WA8204026Medicaid
WAG40630Medicare UPIN
WA8204026Medicaid