Provider Demographics
NPI:1235130279
Name:HWANG, KIM (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HWANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DATES DRIVE
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1342
Mailing Address - Country:US
Mailing Address - Phone:607-277-3790
Mailing Address - Fax:607-277-3849
Practice Address - Street 1:101 DATES DRIVE
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1342
Practice Address - Country:US
Practice Address - Phone:607-277-3790
Practice Address - Fax:607-277-3849
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1848212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01593700Medicaid
NY01593700Medicaid
NYG12759Medicare UPIN