Provider Demographics
NPI:1720036700
Name:KIM, GRACE P (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:P
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:PO BOX 797
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-0797
Mailing Address - Country:US
Mailing Address - Phone:203-659-1599
Mailing Address - Fax:203-382-0189
Practice Address - Street 1:4699 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1830
Practice Address - Country:US
Practice Address - Phone:203-659-1599
Practice Address - Fax:203-382-0189
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031353207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001313535Medicaid
CT001313535Medicaid
110004535Medicare ID - Type Unspecified