Provider Demographics
NPI:1457351702
Name:KIM, SEONG CHEOL (MD)
Entity Type:Individual
Prefix:
First Name:SEONG
Middle Name:CHEOL
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 1:2647 MEADOWWEDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772
Mailing Address - Country:US
Mailing Address - Phone:407-793-4608
Mailing Address - Fax:269-651-1411
Practice Address - Street 1:2647 MEADOWWEDGE LOOP
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772
Practice Address - Country:US
Practice Address - Phone:407-793-4608
Practice Address - Fax:269-651-1411
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0392762083X0100X, 2083P0901X
MISK039276208D00000X
MI4301039276208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4542300Medicaid
MI4542300Medicaid
MI0750004Medicare PIN