Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 88953 | GA |
N | 204E00000X | Oral & Maxillofacial Surgeon | 34607 | OK |
N | 204E00000X | Oral & Maxillofacial Surgeon | MD.205951 | LA |
N | 207YS0123X | Facial Plastic Surgeon | 34607 | OK |
N | 207YX0007X | Plastic Surgeon (Head & Neck) | 34607 | OK |
N | 207YX0007X | Plastic Surgeon (Head & Neck) | 88953 | GA |
NPI | 1598931735 |
---|---|
Provider Name | Mr. Beomjune B Kim |
First Address | Newnan, GA 30265-8001 |
Second Address | Newnan, GA 30265-8001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2008 |
Last Update Date | 24/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
88953 | GA MEDICAL LICENSE (01) | GA |