Provider Demographics
NPI:1255490348
Name:KIM, AGNES (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SERYOUNG
Other - Middle Name:AGNES
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2202
Practice Address - Country:US
Practice Address - Phone:860-679-3343
Practice Address - Fax:860-679-4256
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044570207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1255490348Medicaid
CTD400098837Medicare PIN