Provider Demographics
NPI:1215952288
Name:KIM, SOO-JEONG (MD)
Entity type:Individual
Prefix:
First Name:SOO-JEONG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4909 25TH AVE NE
Mailing Address - Street 2:SEATTLE CHILDRENS AUTISM CENTER
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-4107
Mailing Address - Country:US
Mailing Address - Phone:206-987-8080
Mailing Address - Fax:206-987-8081
Practice Address - Street 1:4909 25TH AVE NE
Practice Address - Street 2:SEATTLE CHILDRENS AUTISM CENTER
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4107
Practice Address - Country:US
Practice Address - Phone:206-987-8080
Practice Address - Fax:206-987-8081
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME963022084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276054100Medicaid
FLI65512Medicare UPIN
FLU8845YMedicare PIN
FLU8845ZMedicare PIN