Healthcare Provider Details

I. General information

NPI: 1114986817
Provider Name (Legal Business Name): DANIEL LEE KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2022
Certification Date: 02/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 ABIGAIL LN
PORT MATILDA PA
16870-7153
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 814-272-5011
  • Fax: 814-272-6531
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberD00065837
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number223931
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD065991L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: