Provider Demographics
NPI:1770355745
Name:KIM, DONGHYEON
Entity type:Individual
Prefix:
First Name:DONGHYEON
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 1:15 KENT CT UNIT 3
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06278-1511
Mailing Address - Country:US
Mailing Address - Phone:959-444-6350
Mailing Address - Fax:
Practice Address - Street 1:600 SLATER RD
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06053-2646
Practice Address - Country:US
Practice Address - Phone:959-444-6350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer