Provider Demographics
NPI:1891718490
Name:KIM, ANTHONY C (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:C
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2501
Mailing Address - Country:US
Mailing Address - Phone:516-458-7127
Mailing Address - Fax:
Practice Address - Street 1:60 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1578
Practice Address - Country:US
Practice Address - Phone:516-222-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208533-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02091349Medicaid
NYA300000557Medicare PIN
NY02091349Medicaid