Provider Demographics
NPI:1366616930
Name:SIU, KIMBERLY (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SIU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:STONY BRROK UNIVERSITY HOSPITAL
Mailing Address - Street 2:MEDICAL STAFF OFFICE T-14
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-7148
Mailing Address - Country:US
Mailing Address - Phone:631-444-2754
Mailing Address - Fax:631-444-6031
Practice Address - Street 1:STONY BRROK UNIVERSITY HOSPITAL
Practice Address - Street 2:DEPT OF PREVENTIVE MEDICINE
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8036
Practice Address - Country:US
Practice Address - Phone:631-444-8265
Practice Address - Fax:631-444-7525
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233090390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program