MEDICARE: DR. HYE TAE KIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K1852	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0017JK	OTHER	TX	BCBS OF TEXAS
2	K1852	OTHER	TX	LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053331470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HYE TAE KIM MD

Provider Business Mailing Address
First Line	:	1157 E 42ND ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79762-7723
Country	:	US
Telephone Number	:	432-550-5300
Fax Number	:	432-366-7100

Provider Business Practice Location Address
First Line	:	1387 GEORGE DIETER DR BLDG B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-7410
Country	:	US
Telephone Number	:	915-275-0224
Fax Number	:	915-275-0225

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	12/02/2022

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