Provider Demographics
NPI:1487159596
Name:KIM, KATELYN MARIKO (MD)
Entity type:Individual
Prefix:DR
First Name:KATELYN
Middle Name:MARIKO
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIKO
Other - Last Name:UPDYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 PRESTON EXECUTIVE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8447
Mailing Address - Country:US
Mailing Address - Phone:919-653-1344
Mailing Address - Fax:
Practice Address - Street 1:110 PRESTON EXECUTIVE DR STE 100
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8447
Practice Address - Country:US
Practice Address - Phone:919-653-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2023-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2022-02027207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program