Healthcare Provider Details

I. General information

NPI: 1285167809
Provider Name (Legal Business Name): SHAWN MYUNGKI KIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

75 SANDPIPER CT
STANTON CA
90680-3183
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2020032351
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: