MEDICARE: KYONG HO KIM DO

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	207L00000X	Anesthesiology Physician	OP00001595	WA
2	208VP0014X	Interventional Pain Medicine Physician	OP00001595	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124009303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYONG HO KIM DO

Provider Business Mailing Address
First Line	:	PO BOX 39324
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98496-3324
Country	:	US
Telephone Number	:	253-983-9390
Fax Number	:	253-983-0066

Provider Business Practice Location Address
First Line	:	11306 BRIDGEPORT WAY SW
Second Line	:	SUITE D
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-3037
Country	:	US
Telephone Number	:	253-983-9390
Fax Number	:	253-983-0066

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	02/15/2023

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Directions to “ KYONG HO KIM DO” Practice Location

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