Provider Demographics
NPI:1720087067
Name:KIM, DOUG SHIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUG
Middle Name:SHIN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:31260 PACIFIC HWY S
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5448
Mailing Address - Country:US
Mailing Address - Phone:253-941-7100
Mailing Address - Fax:253-941-1510
Practice Address - Street 1:31260 PACIFIC HWY S
Practice Address - Street 2:SUITE 3
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5448
Practice Address - Country:US
Practice Address - Phone:253-941-7100
Practice Address - Fax:253-941-1510
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00027275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911891770OtherTAX IDENTIFICATION NUMBER
WA1302280Medicaid
WA78257OtherLABOR AND INDUSTRIES ID
WAKI2297OtherREGENCE PROVIDER ID #
WAE57749Medicare UPIN
WAG8858884Medicare PIN