Provider Demographics
NPI:1871122812
Name:KIM, KWANG
Entity type:Individual
Prefix:
First Name:KWANG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16201 NORTHERN BLVD # 790
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1634
Mailing Address - Country:US
Mailing Address - Phone:516-578-6964
Mailing Address - Fax:
Practice Address - Street 1:16201 NORTHERN BLVD # 790
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1634
Practice Address - Country:US
Practice Address - Phone:516-578-6964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program