Provider Demographics
NPI:1871851220
Name:KIM, ELECIA EUNJU (MD (MAY 2012))
Entity Type:Individual
Prefix:
First Name:ELECIA
Middle Name:EUNJU
Last Name:KIM
Suffix:
Gender:F
Credentials:MD (MAY 2012)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 GASTON AVE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-2016
Mailing Address - Country:US
Mailing Address - Phone:469-800-9000
Mailing Address - Fax:469-800-9010
Practice Address - Street 1:3417 GASTON AVE
Practice Address - Street 2:SUITE 1000
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2016
Practice Address - Country:US
Practice Address - Phone:469-800-9000
Practice Address - Fax:469-800-9010
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ3533207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX442385YNQJMedicare PIN