Provider Demographics
NPI:1982795753
Name:KIM, LISA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
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 1:3355 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-4105
Mailing Address - Country:US
Mailing Address - Phone:410-480-5195
Mailing Address - Fax:410-480-5197
Practice Address - Street 1:3355 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-4105
Practice Address - Country:US
Practice Address - Phone:410-480-5195
Practice Address - Fax:410-480-5197
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052479207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD141887661OtherTAX ID
MD346603500Medicaid
MDBK5584734OtherDEA NUMBER
MD346603500Medicaid
MDBK5584734OtherDEA NUMBER