Healthcare Provider Details

I. General information

NPI: 1801580881
Provider Name (Legal Business Name): DUANE KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4504
US

IV. Provider business mailing address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-8605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberBP10083655
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101284623
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: