Provider Demographics
NPI:1982697363
Name:KIM, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 BEAVER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-3204
Mailing Address - Country:US
Mailing Address - Phone:860-402-1090
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-545-2803
Practice Address - Fax:860-545-1500
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0403582085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001403584Medicaid
920000039Medicare ID - Type Unspecified
F27932Medicare UPIN