Provider Demographics
NPI:1518135862
Name:KIM, KUMOCK (MD)
Entity Type:Individual
Prefix:DR
First Name:KUMOCK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20837 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1042
Mailing Address - Country:US
Mailing Address - Phone:718-614-4565
Mailing Address - Fax:718-423-0150
Practice Address - Street 1:20837 32ND AVE
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1042
Practice Address - Country:US
Practice Address - Phone:718-614-4565
Practice Address - Fax:718-423-0150
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126538-12084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00236044Medicaid