Provider Demographics
NPI:1023111994
Name:KIM, BONNIE B (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:B
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 GRAVEL PIKE
Mailing Address - Street 2:
Mailing Address - City:GREEN LANE
Mailing Address - State:PA
Mailing Address - Zip Code:18054-2215
Mailing Address - Country:US
Mailing Address - Phone:610-348-0402
Mailing Address - Fax:
Practice Address - Street 1:4509 GRAVEL PIKE
Practice Address - Street 2:
Practice Address - City:GREEN LANE
Practice Address - State:PA
Practice Address - Zip Code:18054-2215
Practice Address - Country:US
Practice Address - Phone:610-348-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037535-Y207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000890431Medicaid
PA000890431Medicaid