Provider Demographics
NPI:1750309142
Name:KIM, SAMANG O
Entity Type:Individual
Prefix:DR
First Name:SAMANG
Middle Name:O
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 E 147TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-4204
Mailing Address - Country:US
Mailing Address - Phone:816-348-2260
Mailing Address - Fax:913-495-3751
Practice Address - Street 1:7201 E 147TH ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-4204
Practice Address - Country:US
Practice Address - Phone:816-348-2260
Practice Address - Fax:913-495-3751
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO244759320Medicaid
MO244759320Medicaid
MO244759320Medicaid