Provider Demographics
NPI:1629067483
Name:KIM, YONG R (MD)
Entity Type:Individual
Prefix:DR
First Name:YONG
Middle Name:R
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 1:8635 QUEENS BLVD
Mailing Address - Street 2:SUITE1E
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4434
Mailing Address - Country:US
Mailing Address - Phone:718-205-4544
Mailing Address - Fax:718-205-5594
Practice Address - Street 1:8635 QUEENS BLVD
Practice Address - Street 2:SUITE1E
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4434
Practice Address - Country:US
Practice Address - Phone:718-205-4544
Practice Address - Fax:718-205-5594
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01897034Medicaid
NY06378GOtherGHI-MEDICARE
NY01897034Medicaid
NY06378GMedicare PIN