Provider Demographics
NPI:1083022149
Name:KIM, CHANGRAE (DPM)
Entity Type:Individual
Prefix:DR
First Name:CHANGRAE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BAY CLUB DR APT 5X
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2921
Mailing Address - Country:US
Mailing Address - Phone:917-359-3937
Mailing Address - Fax:
Practice Address - Street 1:6508 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MASPETH
Practice Address - State:NY
Practice Address - Zip Code:11378-2423
Practice Address - Country:US
Practice Address - Phone:917-359-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006653213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery