Healthcare Provider Details

I. General information

NPI: 1053670133
Provider Name (Legal Business Name): ANDREW JEE SOO KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2012
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 ROWLAND ST STE 4190
CLARKSTON GA
30021-2203
US

IV. Provider business mailing address

980 ROWLAND ST STE 4190
CLARKSTON GA
30021-2203
US

V. Phone/Fax

Practice location:
  • Phone: 470-799-0044
  • Fax: 470-799-0045
Mailing address:
  • Phone: 470-799-0044
  • Fax: 470-799-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number078379
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number078379
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number078379
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: