Provider Demographics
NPI:1407972748
Name:KIM, SIMON (MD)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
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 1:2222 N NEVADA AVE STE 2025
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6819
Mailing Address - Country:US
Mailing Address - Phone:303-733-8848
Mailing Address - Fax:
Practice Address - Street 1:2222 N NEVADA AVE STE 2025
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:303-733-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.124196208800000X
MN53371208800000X
CO0061310208800000X
MN104902208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01147109OtherMEDICARE RAILROAD
IAENROLLEDMedicaid
OH0107152Medicaid
MNENROLLEDMedicaid
IAENROLLEDMedicaid
OHH349100Medicare PIN