Provider Demographics
NPI:1568639995
Name:KIM, GIL SOO (MD)
Entity Type:Individual
Prefix:DR
First Name:GIL SOO
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 1:1340 AVALON SQ
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2847
Mailing Address - Country:US
Mailing Address - Phone:917-621-7277
Mailing Address - Fax:
Practice Address - Street 1:475 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3441
Practice Address - Country:US
Practice Address - Phone:631-673-9422
Practice Address - Fax:631-673-9426
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine