Basic Information
| Provider Information | |||||||||
| NPI: | 1275538845 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12510 PROSPERITY DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209041663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404855200 | ||||||||
| FaxNumber: | 3016256906 | ||||||||
| Practice Location | |||||||||
| Address1: | 7350 VAN DUSEN RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014985500 | ||||||||
| FaxNumber: | 3014987346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2016 | ||||||||
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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 | 207RG0100X | D0033979 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | P00679066 | 01 | MD | RAILROAD MEDICARE | OTHER | 531224-01 | 01 | MD | CAREFIRST BSMD | OTHER | N5630029 | 01 | MD | CAREFIRST DC/MD | OTHER | A1110003 | 01 | DC | CAREFIRST BCBS DC | OTHER | A1130004 | 01 | DC | CAREFIRST BCBS DC | OTHER | 275761300 | 05 | MD | MEDICAID | 2516-0002 | 01 | DC | CAREFIRST BSDC | OTHER | 10040326 | 01 | MD | RAILROAD MEDICARE | OTHER |