Provider Demographics
NPI:1740863745
Name:KIM, BYEONGJIK
Entity type:Individual
Prefix:
First Name:BYEONGJIK
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 1:194 BUCKLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8705
Mailing Address - Country:US
Mailing Address - Phone:860-644-0099
Mailing Address - Fax:
Practice Address - Street 1:194 BUCKLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-8705
Practice Address - Country:US
Practice Address - Phone:860-644-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYGD60840BMedicaid