Provider Demographics
NPI:1891179024
Name:KIM, BONG JIK (MD)
Entity Type:Individual
Prefix:MR
First Name:BONG JIK
Middle Name:
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 1:50 NORTH MEDICAL DRIVE 3C120
Mailing Address - Street 2:OTOLARYNGOLOGY ADMINISTRATION OFFICE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132
Mailing Address - Country:US
Mailing Address - Phone:801-581-7514
Mailing Address - Fax:801-585-5744
Practice Address - Street 1:50 NORTH MEDICAL DRIVE 3C120
Practice Address - Street 2:OTOLARYNGOLOGY ADMINISTRATION OFFICE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132
Practice Address - Country:US
Practice Address - Phone:801-581-7514
Practice Address - Fax:801-585-5744
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program