Healthcare Provider Details

I. General information

NPI: 1033199187
Provider Name (Legal Business Name): SEONG SOOL SHIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10090 MEDLOCK BRIDGE RD STE 110
JOHNS CREEK GA
30097-4428
US

IV. Provider business mailing address

10090 MEDLOCK BRIDGE RD STE 110
JOHNS CREEK GA
30097-4428
US

V. Phone/Fax

Practice location:
  • Phone: 470-482-6508
  • Fax: 770-476-9750
Mailing address:
  • Phone: 470-482-6508
  • Fax: 770-476-9750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number78133
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: