Provider Demographics
NPI:1831168517
Name:KIM, DANIEL DAEWOONG (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DAEWOONG
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-256-2467
Mailing Address - Fax:702-838-1456
Practice Address - Street 1:2350 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2149
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-242-7944
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV39574Medicare PIN
I09259Medicare UPIN