Provider Demographics
NPI:1639113806
Name:KIM, DANIEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
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 1:2 PERRYRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4608
Mailing Address - Country:US
Mailing Address - Phone:210-727-5794
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR ST # BB310
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-2572
Practice Address - Fax:203-785-3950
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT68901208600000X
WI72501208600000X
CTPENDING2086S0102X
IN01056918A171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100096288Medicaid