Provider Demographics
NPI:1225533045
Name:KIM, DEREK TAEYOUNG
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:TAEYOUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 E BROADWAY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1245
Practice Address - Country:US
Practice Address - Phone:978-606-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-25
Last Update Date:2018-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program