Provider Demographics
NPI:1205890381
Name:KIM, ANTHONY (M D)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 STRAITS TPKE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1835
Mailing Address - Country:US
Mailing Address - Phone:203-757-8361
Mailing Address - Fax:203-754-9126
Practice Address - Street 1:1579 STRAITS TPKE
Practice Address - Street 2:SUITE 2A
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1835
Practice Address - Country:US
Practice Address - Phone:203-757-8361
Practice Address - Fax:203-754-9126
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041997208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTI04145Medicare UPIN
CT340000364Medicare ID - Type Unspecified