Provider Demographics
NPI:1508904210
Name:KIM, CHULSOON (MD)
Entity Type:Individual
Prefix:DR
First Name:CHULSOON
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 1:3725 75TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6422
Mailing Address - Country:US
Mailing Address - Phone:718-507-6262
Mailing Address - Fax:
Practice Address - Street 1:3725 75TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6422
Practice Address - Country:US
Practice Address - Phone:718-507-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117576-1208D00000X
NY117576-1208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0073578OtherGHI
NY117576-A17OtherHEALTHFIRST
NY673881 CKOtherBLUE CROSS & BLUE SHIELD
NY00218268Medicaid
NYP3602724OtherOXFORD
NY169119OtherELDERPLAN
NY17-00464OtherUNITED HEALTHCARE
P00104843OtherRAILROAD MEDICARE
NY673881 CKOtherBLUE CROSS & BLUE SHIELD
NY117576-A17OtherHEALTHFIRST