Provider Demographics
NPI:1407833932
Name:KIM, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:KIM
Suffix:
Gender:M
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:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-0626
Mailing Address - Country:US
Mailing Address - Phone:631-892-2745
Mailing Address - Fax:631-201-3179
Practice Address - Street 1:113 W ESSEX ST STE 203
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1023
Practice Address - Country:US
Practice Address - Phone:201-880-7766
Practice Address - Fax:201-880-7763
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA082728002086S0122X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
I41972Medicare UPIN