Provider Demographics
NPI:1235157017
Name:KIM, PETER S (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
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 1:1317 3RD AVE
Mailing Address - Street 2:7TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-570-2075
Mailing Address - Fax:212-570-2038
Practice Address - Street 1:1317 3RD AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-570-2075
Practice Address - Fax:212-570-2038
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190910174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01502170Medicaid
F81230Medicare UPIN
NY01502170Medicaid
12J711Medicare PIN