Basic Information
| Provider Information | |||||||||
| NPI: | 1609004415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | WEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9055 KATY FWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770241624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134612915 | ||||||||
| FaxNumber: | 7136470443 | ||||||||
| Practice Location | |||||||||
| Address1: | 9055 KATY FWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770241629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134612915 | ||||||||
| FaxNumber: | 7134615307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P4469 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P4469 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER |