Provider Demographics
NPI:1952325359
Name:KIM, THEODORE Y (DO)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
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 74900
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-4900
Mailing Address - Country:US
Mailing Address - Phone:907-562-0321
Mailing Address - Fax:907-562-2683
Practice Address - Street 1:3851 PIPER ST STE U340
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-6904
Practice Address - Country:US
Practice Address - Phone:907-562-0321
Practice Address - Fax:907-562-0321
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK129714207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKQ00801068OtherRAILROAD MEDICARE
AK1686607Medicaid
AKK169302OtherMEDICARE PTAN