Provider Demographics
NPI:1760001572
Name:KIM, YO SUP (MD)
Entity Type:Individual
Prefix:
First Name:YO SUP
Middle Name:
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 1:1130 W MICHIGAN ST STE 318
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-274-8282
Mailing Address - Fax:
Practice Address - Street 1:1130 W MICHIGAN ST STE 318
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-274-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-11
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program