Provider Demographics
NPI:1992844260
Name:KIM, SOON OK (RPT)
Entity Type:Individual
Prefix:
First Name:SOON OK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1028
Mailing Address - Country:US
Mailing Address - Phone:718-463-2700
Mailing Address - Fax:718-463-6174
Practice Address - Street 1:16410 NORTHERN BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2647
Practice Address - Country:US
Practice Address - Phone:718-463-2700
Practice Address - Fax:718-463-6174
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021153-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2263445Medicaid
NY04995AMedicare ID - Type Unspecified