Provider Demographics
NPI:1255924254
Name:KIM, SANGJEUNG
Entity type:Individual
Prefix:
First Name:SANGJEUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3432 97TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1032
Mailing Address - Country:US
Mailing Address - Phone:760-916-6941
Mailing Address - Fax:
Practice Address - Street 1:3432 97TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11368-1032
Practice Address - Country:US
Practice Address - Phone:760-916-6941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299931225100000X
NJ40QA022357002251X0800X
NY048051-012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist