Provider Demographics
NPI:1801860093
Name:KIM, DONGHOON
Entity Type:Individual
Prefix:
First Name:DONGHOON
Middle Name:
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 1:5200 CENTRE AVE
Mailing Address - Street 2:SHADYSIDE MEDICAL BUILDING SUITE 610
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15232-1300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5200 CENTRE AVE
Practice Address - Street 2:SHADYSIDE MEDICAL BUILDING SUITE 610
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1300
Practice Address - Country:US
Practice Address - Phone:412-621-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD071051L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001810720Medicaid
PAH21138Medicare UPIN
PA040019GAHMedicare UPIN