Basic Information
| Provider Information | |||||||||
| NPI: | 1821524331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | YONWOOK | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 CENTENNIAL DR | ||||||||
| Address2: | |||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019607901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785314400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083636208 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207WX0009X | 292643 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | 207W00000X | 309282 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.