1992706543 NPI number — DR. GWANG OCH KIM MD

Table of content: DR. GWANG OCH KIM MD (NPI 1992706543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992706543 NPI number — DR. GWANG OCH KIM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
GWANG
Provider Middle Name:
OCH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992706543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1031 PIERCE STREET
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
SANDUSKY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-557-5541
Provider Business Mailing Address Fax Number:
419-557-5542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2819 HAYES AVE
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
SANDUSKY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44870-5391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-627-8403
Provider Business Practice Location Address Fax Number:
419-627-1962
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  35 040705 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 390007082 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000129590 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0364690 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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