Healthcare Provider Details

I. General information

NPI: 1164307864
Provider Name (Legal Business Name): DEOKHO KIM DIPL. AC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5840 BANNEKER RD STE 220
COLUMBIA MD
21044-3169
US

IV. Provider business mailing address

10773 FOLKESTONE WAY
WOODSTOCK MD
21163-1313
US

V. Phone/Fax

Practice location:
  • Phone: 240-753-0085
  • Fax: 240-388-9113
Mailing address:
  • Phone: 215-272-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU03230
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: