Provider Demographics
NPI:1801827795
Name:KIM, MARTIN SUNG (OD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:SUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:234 KNOX AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2510
Mailing Address - Country:US
Mailing Address - Phone:201-421-9319
Mailing Address - Fax:201-945-3470
Practice Address - Street 1:121 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1441
Practice Address - Country:US
Practice Address - Phone:201-346-1500
Practice Address - Fax:201-346-1549
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006044152W00000X
NJ27OA00604800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02837805Medicaid
NJ0129011Medicaid
NYC521A1Medicare PIN
NJ0129011Medicaid