Basic Information
| Provider Information | |||||||||
| NPI: | 1063687929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | KYUNG HO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066064201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4752105847 | ||||||||
| FaxNumber: | 8609727040 | ||||||||
| Practice Location | |||||||||
| Address1: | DEPT OF MEDICINE STONY BROOK UNIVERSITY | ||||||||
| Address2: | HEALTH SCIENCES CENTER LEVEL 16 RM 020 | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6465229816 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2008 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 69785 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 69785 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | 235372 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.