Provider Demographics
NPI:1295736338
Name:KIM, CHARLES Y (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:Y
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 1:7177 MEADOWBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-2552
Mailing Address - Country:US
Mailing Address - Phone:301-663-3203
Mailing Address - Fax:
Practice Address - Street 1:187 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 7
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4503
Practice Address - Country:US
Practice Address - Phone:301-695-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD188191400Medicaid
MDD76518Medicare UPIN
MD188191400Medicaid