Provider Demographics
NPI:1942241518
Name:KIM, MYUNGDUK ROGER (MD)
Entity Type:Individual
Prefix:
First Name:MYUNGDUK
Middle Name:ROGER
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROGER
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1 BROOKDALE PLAZA, STRAUSBERG SUITE 244
Mailing Address - Street 2:BROOKDALE UNIVERSITY HOSPITAL AND MEDICAL CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212
Mailing Address - Country:US
Mailing Address - Phone:718-240-5628
Mailing Address - Fax:718-240-6513
Practice Address - Street 1:1 BROOKDALE PLZ
Practice Address - Street 2:ROOM 244
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3139
Practice Address - Country:US
Practice Address - Phone:718-240-5668
Practice Address - Fax:718-240-6513
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178690208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01404448Medicaid
NY476Y21Medicare ID - Type Unspecified
H52344Medicare UPIN