Provider Demographics
NPI:1891719860
Name:KIM, CHANG SOO (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANG SOO
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 1:999 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5546
Mailing Address - Country:US
Mailing Address - Phone:203-920-1444
Mailing Address - Fax:866-920-5178
Practice Address - Street 1:999 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5546
Practice Address - Country:US
Practice Address - Phone:203-920-1444
Practice Address - Fax:866-920-5178
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07582400208200000X
CT048229208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH88270Medicare UPIN
NJ071055Medicare ID - Type Unspecified