=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902330400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANG YONG KIM DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 06/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 RANDOLPH RD
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-2257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-206-6274
-----------------------------------------------------
Fax | 240-599-4344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4701 RANDOLPH RD STE 103
-----------------------------------------------------
City | ROCKVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20852-2260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-206-6274
-----------------------------------------------------
Fax | 240-599-4344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 01780
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 0103301376
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------