Provider Demographics
NPI:1124664719
Name:KIM, HARRISON DONGSOO
Entity type:Individual
Prefix:
First Name:HARRISON
Middle Name:DONGSOO
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 WESTGATE DR.
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024
Mailing Address - Country:US
Mailing Address - Phone:315-200-4860
Mailing Address - Fax:
Practice Address - Street 1:17 BRINKERHOFF TER FL 2
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1101
Practice Address - Country:US
Practice Address - Phone:315-200-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006575171100000X
NJ25MZ00150500171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist