Healthcare Provider Details

I. General information

NPI: 1942060611
Provider Name (Legal Business Name): RICHARD WONJOONG KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

1630 10TH AVE APT C
SAN FRANCISCO CA
94122-3625
US

V. Phone/Fax

Practice location:
  • Phone: 347-798-9213
  • Fax:
Mailing address:
  • Phone: 714-767-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: