Provider Demographics
NPI:1518166420
Name:KIM, BERNARD HAKSOO (MD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:HAKSOO
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BERNARD
Other - Middle Name:HAKSOO
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:20 PROSPECT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1997
Mailing Address - Country:US
Mailing Address - Phone:201-996-4849
Mailing Address - Fax:551-996-5703
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:201-996-4849
Practice Address - Fax:551-996-5703
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248070207RC0000X
NJ25MA07795000207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02961053Medicaid
NY02961053Medicaid