Provider Demographics
NPI:1164609863
Name:KIM, DONGSOO (PHD)
Entity Type:Individual
Prefix:DR
First Name:DONGSOO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 ENGLE ST 1A
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-894-1115
Mailing Address - Fax:201-391-1799
Practice Address - Street 1:163 ENGLE ST STE 1A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2530
Practice Address - Country:US
Practice Address - Phone:201-894-1115
Practice Address - Fax:201-391-1799
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00419400103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist