Provider Demographics
NPI:1154323046
Name:KIM, KANG K (MD)
Entity Type:Individual
Prefix:
First Name:KANG
Middle Name:K
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 1:1 WEBSTER AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1361
Mailing Address - Country:US
Mailing Address - Phone:845-471-1002
Mailing Address - Fax:845-471-1003
Practice Address - Street 1:1 WEBSTER AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1361
Practice Address - Country:US
Practice Address - Phone:845-471-1002
Practice Address - Fax:845-471-1003
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00538156Medicaid
285951Medicare ID - Type Unspecified
NY00538156Medicaid