Provider Demographics
NPI:1508922527
Name:PAK, KEVIN I (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:I
Last Name:PAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IKYO
Other - Middle Name:
Other - Last Name:PAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7206 NORTHERN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1049
Mailing Address - Country:US
Mailing Address - Phone:866-670-6824
Mailing Address - Fax:178-533-1774
Practice Address - Street 1:7206 NORTHERN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1049
Practice Address - Country:US
Practice Address - Phone:866-670-6824
Practice Address - Fax:178-533-1774
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT184507208100000X
NY247616-B182081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03143491Medicaid
NY03143491Medicaid