Provider Demographics
NPI:1164488508
Name:KIM, TAE HO (MD)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:HO
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 1:115 WASHINGTON PL
Mailing Address - Street 2:UNIT B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-6803
Mailing Address - Country:US
Mailing Address - Phone:212-706-8738
Mailing Address - Fax:212-706-8743
Practice Address - Street 1:115 WASHINGTON PL
Practice Address - Street 2:UNIT B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-6803
Practice Address - Country:US
Practice Address - Phone:212-706-8738
Practice Address - Fax:212-706-8743
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23843012086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729642Medicaid
NY02729642Medicaid
NY2121F1Medicare PIN