Provider Demographics
NPI:1205916251
Name:KIM, KYUNGSOOK C (MD)
Entity type:Individual
Prefix:
First Name:KYUNGSOOK
Middle Name:C
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:115 WOODBINE LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-3101
Practice Address - Country:US
Practice Address - Phone:570-271-6070
Practice Address - Fax:570-271-5609
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA65893207Q00000X
PAMD062622L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G63571Medicare UPIN