Provider Demographics
NPI:1659404366
Name:KIM, ELIZABETH EON (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:EON
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 JASSAMINE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1621
Mailing Address - Country:US
Mailing Address - Phone:212-733-9796
Mailing Address - Fax:646-441-4163
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:917-826-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07697000204C00000X
NY202911207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG78153Medicare UPIN