Healthcare Provider Details

I. General information

NPI: 1740742782
Provider Name (Legal Business Name): ELEANOR KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

622 W 168TH ST
NEW YORK NY
10032-3720
US

V. Phone/Fax

Practice location:
  • Phone: 626-383-3626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number326070-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: