Provider Demographics
NPI:1942217617
Name:KIM, SOONKYUM (MD)
Entity Type:Individual
Prefix:
First Name:SOONKYUM
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 WEST JERSEY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202
Mailing Address - Country:US
Mailing Address - Phone:908-352-8383
Mailing Address - Fax:
Practice Address - Street 1:230 WEST JERSEY ST STE 102
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202
Practice Address - Country:US
Practice Address - Phone:908-352-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA40076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3945600Medicaid
NJ3945600Medicaid