Provider Demographics
NPI:1932106911
Name:KIM, YOUNG KWAN (DO)
Entity Type:Individual
Prefix:MR
First Name:YOUNG
Middle Name:KWAN
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:8569 SUDLEY RD STE B
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-3866
Mailing Address - Country:US
Mailing Address - Phone:703-257-7749
Mailing Address - Fax:855-254-4529
Practice Address - Street 1:8569 SUDLEY RD STE B
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3866
Practice Address - Country:US
Practice Address - Phone:703-257-7749
Practice Address - Fax:855-254-4529
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102050147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA110007034Medicare ID - Type Unspecified
VAVV7921AMedicare PIN
VAG66476Medicare UPIN
VA5822297Medicare ID - Type Unspecified