Provider Demographics
NPI:1144405838
Name:KIM, AEYOUNG L (MD)
Entity Type:Individual
Prefix:
First Name:AEYOUNG
Middle Name:L
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PARK DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1727
Mailing Address - Country:US
Mailing Address - Phone:845-679-8728
Mailing Address - Fax:845-679-1034
Practice Address - Street 1:40 PARK DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-1727
Practice Address - Country:US
Practice Address - Phone:845-679-8728
Practice Address - Fax:845-679-1034
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108203207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC11753Medicare UPIN