Provider Demographics
NPI:1679614762
Name:DOMM, KATHLEEN KANG (MD)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KANG
Last Name:DOMM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2051 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5834
Mailing Address - Country:US
Mailing Address - Phone:843-573-2535
Mailing Address - Fax:843-573-2534
Practice Address - Street 1:2051 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5834
Practice Address - Country:US
Practice Address - Phone:843-573-2535
Practice Address - Fax:843-573-2534
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86527208000000X
SC30181208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics