Basic Information
| Provider Information | |||||||||
| NPI: | 1891179024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | BONG JIK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 NORTH MEDICAL DRIVE 3C120 | ||||||||
| Address2: | OTOLARYNGOLOGY ADMINISTRATION OFFICE | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817514 | ||||||||
| FaxNumber: | 8015855744 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 NORTH MEDICAL DRIVE 3C120 | ||||||||
| Address2: | OTOLARYNGOLOGY ADMINISTRATION OFFICE | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817514 | ||||||||
| FaxNumber: | 8015855744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2015 | ||||||||
| LastUpdateDate: | 07/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.