Provider Demographics
NPI:1215970967
Name:KIM, HAZEL H (MD)
Entity type:Individual
Prefix:
First Name:HAZEL
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HAE
Other - Middle Name:SOOK
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:65 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3947
Mailing Address - Country:US
Mailing Address - Phone:732-321-7680
Mailing Address - Fax:732-321-7008
Practice Address - Street 1:65 JAMES ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3947
Practice Address - Country:US
Practice Address - Phone:732-321-7680
Practice Address - Fax:732-321-7008
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03785800207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2010500Medicaid
NJ2010500Medicaid
NJ195681Medicare ID - Type Unspecified