Healthcare Provider Details

I. General information

NPI: 1801827795
Provider Name (Legal Business Name): MARTIN SUNG KIM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 BROAD AVE
PALISADES PARK NJ
07650-1441
US

IV. Provider business mailing address

234 KNOX AVE UNIT B
CLIFFSIDE PARK NJ
07010-2510
US

V. Phone/Fax

Practice location:
  • Phone: 201-346-1500
  • Fax: 201-346-1549
Mailing address:
  • Phone: 201-421-9319
  • Fax: 201-945-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number006044
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00604800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: