Basic Information
| Provider Information | |||||||||
| NPI: | 1912319120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | NGOC | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | NGOC | ||||||||
| OtherMiddleName: | KIM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089048477 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HEALTHY WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115721551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166323934 | ||||||||
| FaxNumber: | 5166638955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 02/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 289734 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.