Provider Demographics
NPI:1164430468
Name:KIM, CHRISTOPHER C (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:80 REVERE BLVD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1907
Mailing Address - Country:US
Mailing Address - Phone:732-669-0077
Mailing Address - Fax:732-669-0076
Practice Address - Street 1:34 PROGRESS ST # 36
Practice Address - Street 2:SUITE A 7
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1103
Practice Address - Country:US
Practice Address - Phone:732-669-0077
Practice Address - Fax:732-669-0076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07159600208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8968209Medicaid
NJ8968209Medicaid
NJ048706Medicare ID - Type Unspecified