Provider Demographics
NPI:1851300461
Name:KIM, MAX CHUNG HO (MD)
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:CHUNG HO
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 1:20940 N TATUM BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7254
Mailing Address - Country:US
Mailing Address - Phone:480-538-7075
Mailing Address - Fax:480-538-7952
Practice Address - Street 1:20940 N TATUM BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4265
Practice Address - Country:US
Practice Address - Phone:480-538-7075
Practice Address - Fax:480-538-7952
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35715207W00000X, 207WX0009X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI61313Medicare UPIN