Provider Demographics
NPI:1629092465
Name:KIM, VICTOR YONGHOON (MD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:YONGHOON
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 1:5074 DORSEY HALL DR STE 104
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7794
Mailing Address - Country:US
Mailing Address - Phone:443-766-3332
Mailing Address - Fax:410-480-2336
Practice Address - Street 1:5074 DORSEY HALL DR STE 104
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7794
Practice Address - Country:US
Practice Address - Phone:443-766-3332
Practice Address - Fax:410-480-2336
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD51586207RG0300X
MDD0051586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0051586OtherMEDICAL LICENSE
MD416570500Medicaid
MD022004300Medicaid
MD2101043822Medicare ID - Type Unspecified
MD690301100Medicaid