Provider Demographics
NPI:1144752122
Name:KIM, MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
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 1:145 WYCKOFF RD STE 301
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1887
Mailing Address - Country:US
Mailing Address - Phone:848-208-5250
Mailing Address - Fax:732-935-1590
Practice Address - Street 1:145 WYCKOFF RD STE 301
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1887
Practice Address - Country:US
Practice Address - Phone:848-208-5250
Practice Address - Fax:732-935-1590
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11030700207Q00000X, 207QS0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program