Provider Demographics
NPI:1023095643
Name:KIM, SOON JA (MD)
Entity type:Individual
Prefix:
First Name:SOON
Middle Name:JA
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
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Mailing Address - Street 1:5808 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5105
Mailing Address - Country:US
Mailing Address - Phone:410-796-7730
Mailing Address - Fax:410-379-1537
Practice Address - Street 1:5808 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-5105
Practice Address - Country:US
Practice Address - Phone:410-796-7730
Practice Address - Fax:410-379-1537
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0022832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD794391100Medicaid
D71548Medicare UPIN
MD4933Medicare ID - Type Unspecified