Provider Demographics
NPI:1215969456
Name:KIM, DEBORAH L (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:16985 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5909
Practice Address - Country:US
Practice Address - Phone:262-641-8400
Practice Address - Fax:262-784-3921
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34528208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32164500Medicaid
WI32164500Medicaid
WI01994-0259Medicare PIN
G11585Medicare UPIN