Healthcare Provider Details

I. General information

NPI: 1235383464
Provider Name (Legal Business Name): MYUNG MI KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD ST
FORT POLK LA
71459-5102
US

IV. Provider business mailing address

PO BOX 19781
HOUSTON TX
77224-9781
US

V. Phone/Fax

Practice location:
  • Phone: 726-780-2411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2013-00050
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberW0821
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number169774
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1060118
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: