Provider Demographics
NPI:1639146467
Name:KIM, MICHAEL CHUNGUCK (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHUNGUCK
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:PO BOX 61896
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-1896
Mailing Address - Country:US
Mailing Address - Phone:360-823-2012
Mailing Address - Fax:360-823-2260
Practice Address - Street 1:3200 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663
Practice Address - Country:US
Practice Address - Phone:360-696-4691
Practice Address - Fax:360-823-2260
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038580207W00000X
ORMD22633207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8255838Medicaid
WA8255838Medicaid
H09861Medicare UPIN
WA8255838Medicaid
WA0594300001Medicare NSC
AB15259Medicare ID - Type Unspecified