Provider Demographics
NPI:1174753172
Name:KIM, SANG TAEK (MD)
Entity type:Individual
Prefix:
First Name:SANG TAEK
Middle Name:
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 1:330 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4417
Mailing Address - Country:US
Mailing Address - Phone:203-680-7050
Mailing Address - Fax:
Practice Address - Street 1:330 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4417
Practice Address - Country:US
Practice Address - Phone:203-680-7050
Practice Address - Fax:203-785-7053
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-24
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT047978207RR0500X
TXQ6526207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354544401Medicaid
TX354544402OtherRHEUMATOLOGY