Provider Demographics
NPI:1740742824
Name:KIM, DANIEL CHAN KYUM (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:CHAN KYUM
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 1:9225 N 3RD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2466
Mailing Address - Country:US
Mailing Address - Phone:602-445-0751
Mailing Address - Fax:602-424-8128
Practice Address - Street 1:250 E DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2825
Practice Address - Country:US
Practice Address - Phone:602-445-0751
Practice Address - Fax:602-424-8128
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009558207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ153907Medicaid
AZ009558OtherAZ DO LICENSE