Provider Demographics
NPI:1417742404
Name:KIM, ETHAN (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 PAGE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-2320
Mailing Address - Country:US
Mailing Address - Phone:267-247-2896
Mailing Address - Fax:
Practice Address - Street 1:915 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6699
Practice Address - Country:US
Practice Address - Phone:229-551-2576
Practice Address - Fax:229-584-7154
Is Sole Proprietor?:No
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program