Healthcare Provider Details

I. General information

NPI: 1205762614
Provider Name (Legal Business Name): GENE WOO KIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 PEACH ST
ERIE PA
16509-2695
US

IV. Provider business mailing address

5515 PEACH ST
ERIE PA
16509-2603
US

V. Phone/Fax

Practice location:
  • Phone: 814-868-4031
  • Fax:
Mailing address:
  • Phone: 814-868-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT025737
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: