Provider Demographics
NPI:1306850433
Name:KIM, STANLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
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 1:34-36 PROGRESS STREET
Mailing Address - Street 2:SUITE A7
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820
Mailing Address - Country:US
Mailing Address - Phone:908-769-1440
Mailing Address - Fax:
Practice Address - Street 1:34 PROGRESS ST # 36
Practice Address - Street 2:SUITE A7
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1103
Practice Address - Country:US
Practice Address - Phone:908-769-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7879601Medicaid
NJ878740VXFMedicare PIN
NJ7879601Medicaid
NJ878740VYHMedicare PIN
NJ878740NFVMedicare PIN