Provider Demographics
NPI:1174904023
Name:KIM, HWAN (MD)
Entity type:Individual
Prefix:
First Name:HWAN
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 1:224-D CORNWALL STREET, NW.
Mailing Address - Street 2:SUITE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:
Practice Address - Street 1:19441 GOLF VISTA PLAZA SUITE 230 & 310
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8272
Practice Address - Country:US
Practice Address - Phone:703-729-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT62325207R00000X, 208M00000X
NJ390200000X
VA0101279380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174904023Medicaid
VA30017658760001Medicaid