Provider Demographics
NPI:1992706543
Name:KIM, GWANG OCH (MD)
Entity type:Individual
Prefix:DR
First Name:GWANG
Middle Name:OCH
Last Name:KIM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:1031 PIERCE STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-557-5541
Mailing Address - Fax:419-557-5542
Practice Address - Street 1:2819 HAYES AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5391
Practice Address - Country:US
Practice Address - Phone:419-627-8403
Practice Address - Fax:419-627-1962
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2012-09-12
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Provider Licenses
StateLicense IDTaxonomies
OH35 040705207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH390007082OtherRAILROAD MEDICARE
OH000000129590OtherANTHEM BCBS
OH0364690Medicaid
OH000000129590OtherANTHEM BCBS
A77389Medicare UPIN