Provider Demographics
NPI:1740223197
Name:KIM, BONG SONG (MD)
Entity Type:Individual
Prefix:DR
First Name:BONG SONG
Middle Name:
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 1:4020 MAIN ST
Mailing Address - Street 2:4TH FL.
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5519
Mailing Address - Country:US
Mailing Address - Phone:347-532-2888
Mailing Address - Fax:
Practice Address - Street 1:4020 MAIN ST
Practice Address - Street 2:4TH FL.
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5519
Practice Address - Country:US
Practice Address - Phone:347-532-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1151952085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01026053Medicaid
NY4592944OtherAETNA
NY913151OtherEMPIRE B/C B/S
NY4592944OtherAETNA
NY01026053Medicaid