Provider Demographics
NPI:1922055326
Name:KIM, DUCKSOO (MD)
Entity Type:Individual
Prefix:
First Name:DUCKSOO
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 1:9 CEDAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-1631
Mailing Address - Country:US
Mailing Address - Phone:508-395-3110
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:857-203-6414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA415752085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6171095Medicaid
MA6171095Medicaid
MAB96430Medicare UPIN