Provider Demographics
NPI:1902330400
Name:KIM, CHANG YONG (DPM)
Entity Type:Individual
Prefix:
First Name:CHANG YONG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 TELESTAR CT
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22042-1206
Mailing Address - Country:US
Mailing Address - Phone:703-584-2040
Mailing Address - Fax:703-560-7218
Practice Address - Street 1:2922 TELESTAR CT
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-1206
Practice Address - Country:US
Practice Address - Phone:703-584-2040
Practice Address - Fax:703-560-7218
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301376213E00000X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program