Provider Demographics
NPI:1508005240
Name:KIM, CECIL S (MD)
Entity Type:Individual
Prefix:
First Name:CECIL
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 1:160 W 66 ST
Mailing Address - Street 2:#24E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6559
Mailing Address - Country:US
Mailing Address - Phone:212-799-0366
Mailing Address - Fax:
Practice Address - Street 1:160 W 66 ST
Practice Address - Street 2:#24E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-6559
Practice Address - Country:US
Practice Address - Phone:212-799-0366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105884207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC11598Medicare UPIN