Healthcare Provider Details

I. General information

NPI: 1558823922
Provider Name (Legal Business Name): NATHAN SUNG IN KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 LPGA BLVD STE 170
DAYTONA BEACH FL
32117-7131
US

IV. Provider business mailing address

1890 LPGA BLVD STE 170
DAYTONA BEACH FL
32117-7131
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME148046
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: