Provider Demographics
NPI:1164012746
Name:DR. P.KIM PODIATRY, P.C.
Entity Type:Organization
Organization Name:DR. P.KIM PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:267-979-9670
Mailing Address - Street 1:18820B 69TH AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3705
Mailing Address - Country:US
Mailing Address - Phone:646-762-4331
Mailing Address - Fax:888-720-0690
Practice Address - Street 1:14218 38TH AVE STE 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5654
Practice Address - Country:US
Practice Address - Phone:646-762-4331
Practice Address - Fax:888-720-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04389222Medicaid