Healthcare Provider Details

I. General information

NPI: 1528045242
Provider Name (Legal Business Name): KWANG HO KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

3 BOYLE RD
SELDEN NY
11784-4030
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4088
  • Fax:
Mailing address:
  • Phone: 631-736-4064
  • Fax: 631-736-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number1875391
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: