Provider Demographics
NPI:1841394442
Name:KIM, TAE W (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:W
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 1:6929 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-274-8377
Mailing Address - Fax:937-274-8377
Practice Address - Street 1:6929 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415
Practice Address - Country:US
Practice Address - Phone:937-274-8377
Practice Address - Fax:937-274-8377
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100294207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0482768Medicaid
OH0482768Medicaid
KI0413441Medicare ID - Type Unspecified