Provider Demographics
NPI:1770392466
Name:KIM, WONTAK MILES
Entity type:Individual
Prefix:
First Name:WONTAK
Middle Name:MILES
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14722 S RISING STAR WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5809
Mailing Address - Country:US
Mailing Address - Phone:801-382-8435
Mailing Address - Fax:
Practice Address - Street 1:2000 CIRCLE OF HOPE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-382-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program