Healthcare Provider Details

I. General information

NPI: 1225536915
Provider Name (Legal Business Name): DOCTOR K LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2018
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5074 DORSEY HALL DR STE 104
ELLICOTT CITY MD
21042-7794
US

IV. Provider business mailing address

5074 DORSEY HALL DR STE 104
ELLICOTT CITY MD
21042-7794
US

V. Phone/Fax

Practice location:
  • Phone: 443-766-3332
  • Fax:
Mailing address:
  • Phone: 443-766-3332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD51586
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTOR Y KIM
Title or Position: OWNER
Credential: M.D.
Phone: 443-570-8035