Provider Demographics
NPI:1699833327
Name:KIM, BACK KYUN (MD)
Entity Type:Individual
Prefix:DR
First Name:BACK
Middle Name:KYUN
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:13620 38TH AVE
Mailing Address - Street 2:SUITE 8J
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4277
Mailing Address - Country:US
Mailing Address - Phone:718-997-9000
Mailing Address - Fax:718-997-8880
Practice Address - Street 1:13668 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5510
Practice Address - Country:US
Practice Address - Phone:718-997-9000
Practice Address - Fax:718-997-8880
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202578207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01753162Medicaid
NY02524BMedicare ID - Type Unspecified
NY01753162Medicaid