Provider Demographics
NPI:1124492467
Name:KIM, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 8TH AVE
Mailing Address - Street 2:APT 5B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-6203
Mailing Address - Country:US
Mailing Address - Phone:847-322-2345
Mailing Address - Fax:
Practice Address - Street 1:455 W 37TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4081
Practice Address - Country:US
Practice Address - Phone:212-643-6090
Practice Address - Fax:212-643-6094
Is Sole Proprietor?:No
Enumeration Date:2015-11-24
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist