Provider Demographics
NPI:1154359826
Name:KIM, DAVID D (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:D
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10206 CAMP RICE POINT RD
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-9545
Mailing Address - Country:US
Mailing Address - Phone:920-217-2808
Mailing Address - Fax:928-268-0184
Practice Address - Street 1:10206 CAMP RICE POINT RD
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-9545
Practice Address - Country:US
Practice Address - Phone:920-217-2808
Practice Address - Fax:928-268-0184
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036145713207R00000X
MO2020001911207R00000X
WI32318-20207WX0009X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1477532174Medicaid
WI07028-0166Medicare PIN
WIF91969Medicare UPIN