Provider Demographics
NPI:1336225432
Name:KIM, BONG SUP (MD)
Entity Type:Individual
Prefix:DR
First Name:BONG SUP
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 1:15208 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-6124
Mailing Address - Country:US
Mailing Address - Phone:206-362-3361
Mailing Address - Fax:206-362-7055
Practice Address - Street 1:15208 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-6124
Practice Address - Country:US
Practice Address - Phone:206-362-3361
Practice Address - Fax:206-362-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00023608207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1068048Medicaid
WA000108687Medicare ID - Type Unspecified
WA1068048Medicaid