Provider Demographics
NPI:1790753762
Name:KIM, SUNG YONG (MD)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:YONG
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 1:3409 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3219
Mailing Address - Country:US
Mailing Address - Phone:757-399-0705
Mailing Address - Fax:757-399-3978
Practice Address - Street 1:3409 SOUTH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3219
Practice Address - Country:US
Practice Address - Phone:757-399-0705
Practice Address - Fax:757-399-3978
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101022964174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6745075Medicaid
VAB61835Medicare UPIN