Provider Demographics
NPI:1194775254
Name:KIM, DENNIS W (MD, PHD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:W
Last Name:KIM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 BRANDYWINE RD
Mailing Address - Street 2:300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-5510
Mailing Address - Country:US
Mailing Address - Phone:770-488-9212
Mailing Address - Fax:770-488-9408
Practice Address - Street 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1549
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0527622080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA521781413AMedicaid
H64352Medicare UPIN