Provider Demographics
NPI:1366400590
Name:KIM, MICHAEL KWANGSOO (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KWANGSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 CENTRAL AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7649
Mailing Address - Country:US
Mailing Address - Phone:239-939-5233
Mailing Address - Fax:239-939-9225
Practice Address - Street 1:3700 CENTRAL AVE
Practice Address - Street 2:STE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7649
Practice Address - Country:US
Practice Address - Phone:239-939-5233
Practice Address - Fax:239-939-9225
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME788332086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL49398YMedicare ID - Type UnspecifiedMEDICARE
FLG000391Medicare UPIN