Provider Demographics
NPI:1477538908
Name:KIM, SUNG JO (MD)
Entity type:Individual
Prefix:
First Name:SUNG JO
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:STE F
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4886
Mailing Address - Country:US
Mailing Address - Phone:631-654-8755
Mailing Address - Fax:631-654-8709
Practice Address - Street 1:260 PATCHOGUE YAPHANK RD
Practice Address - Street 2:STE F
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4886
Practice Address - Country:US
Practice Address - Phone:631-654-8755
Practice Address - Fax:631-654-8709
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY121585207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
W38231OtherMEDICARE GROUP NUMBER
NY00228217Medicaid
W38231OtherMEDICARE GROUP NUMBER
C08366Medicare UPIN