Basic Information
| Provider Information | |||||||||
| NPI: | 1992721724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683196 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683140 | ||||||||
| FaxNumber: | 5083683196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | MD049272L | PA | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 2082S0105X | 78337 | MA | Y | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 110053618A | 05 | MA | MEDICAID |