Provider Demographics
NPI:1558398214
Name:IM, WICHAE (MD)
Entity Type:Individual
Prefix:
First Name:WICHAE
Middle Name:
Last Name:IM
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 1:7901 BROADWAY
Mailing Address - Street 2:ROOM A1-9
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-344-2600
Mailing Address - Fax:718-344-2623
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:ROOM A1-9
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-4952
Practice Address - Fax:718-334-4815
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198358208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01862922Medicaid
NY5265TQMedicare PIN
NYG79019Medicare UPIN