Provider Demographics
NPI:1952340945
Name:KIM, GRACE WONJA (MD)
Entity Type:Individual
Prefix:
First Name:GRACE WONJA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 HAVERHILL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-1509
Mailing Address - Country:US
Mailing Address - Phone:978-475-5656
Mailing Address - Fax:
Practice Address - Street 1:138 HAVERHILL ST
Practice Address - Street 2:DOCTORS' PARK II
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-1509
Practice Address - Country:US
Practice Address - Phone:978-475-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46202207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine