Provider Demographics
NPI:1982694618
Name:KIM, THEODORE TAE-HUN (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:TAE-HUN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TAE
Other - Middle Name:HUN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:14520 AVION PKWY STE 150
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1165
Practice Address - Country:US
Practice Address - Phone:703-378-5155
Practice Address - Fax:703-378-5166
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239690207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982694618Medicaid
DCG02511A01OtherMEDICARE PTAN
VA774606OtherNCPPO
VA7190863OtherAETNA
VA5162897OtherUNITED HEALTH CARE
DCG02511A01OtherMEDICARE PTAN
VA1660925OtherAETNA
VA010326338Medicaid