Provider Demographics
NPI:1912978982
Name:KIM, DOHYUNG (PT)
Entity Type:Individual
Prefix:
First Name:DOHYUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 NORTHERN BLVD
Mailing Address - Street 2:STE 2E
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5035
Mailing Address - Country:US
Mailing Address - Phone:718-888-1641
Mailing Address - Fax:718-888-2514
Practice Address - Street 1:15301 NORTHERN BLVD
Practice Address - Street 2:STE 2E
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5035
Practice Address - Country:US
Practice Address - Phone:718-888-1641
Practice Address - Fax:718-888-2514
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019722174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74981OtherCAREPLUS
NY02590958Medicaid
NY04661Medicare ID - Type UnspecifiedGHI MEDICARE
NY02590958Medicaid