Provider Demographics
NPI:1104059773
Name:KIM, RANDIE (MD, PHD)
Entity type:Individual
Prefix:
First Name:RANDIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FIRST AVENUE
Mailing Address - Street 2:NYU LANGONE MEDICAL CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-263-5506
Mailing Address - Fax:
Practice Address - Street 1:550 FIRST AVENUE
Practice Address - Street 2:NYU LANGONE MEDICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275296207N00000X, 207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400147777Medicare UPIN