Provider Demographics
NPI:1073772638
Name:KIM, TAEGYUN (MD)
Entity Type:Individual
Prefix:
First Name:TAEGYUN
Middle Name:
Last Name:KIM
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 1:150-38 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:20748
Mailing Address - Country:US
Mailing Address - Phone:301-318-0507
Mailing Address - Fax:
Practice Address - Street 1:141-47 NORTHERN BLVD.
Practice Address - Street 2:SUITEE #2R
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-461-2701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-08
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263541207R00000X
MA235558208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist