Provider Demographics
NPI:1710974514
Name:PODOLNICK, KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:PODOLNICK
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 1:990 STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4822
Mailing Address - Country:US
Mailing Address - Phone:516-222-2022
Mailing Address - Fax:
Practice Address - Street 1:990 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4822
Practice Address - Country:US
Practice Address - Phone:516-222-2022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1362792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB13801Medicare UPIN
NY28041JMedicare ID - Type Unspecified