Healthcare Provider Details

I. General information

NPI: 1396102828
Provider Name (Legal Business Name): DR. P.KIM PODIATRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6083 MYRTLE AVE
RIDGEWOOD NY
11385-5908
US

IV. Provider business mailing address

18820B 69TH AVE APT 3B
FRESH MEADOWS NY
11365-3705
US

V. Phone/Fax

Practice location:
  • Phone: 718-381-8402
  • Fax: 718-497-7322
Mailing address:
  • Phone: 267-979-9670
  • Fax: 888-720-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006427
License Number StateNY

VIII. Authorized Official

Name: PAUL Y KIM
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 267-979-9670