Provider Demographics
NPI:1528353273
Name:KIM, SOO CHONG (MD)
Entity type:Individual
Prefix:DR
First Name:SOO CHONG
Middle Name:
Last Name:KIM
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 1:360 ESSEX ST STE 401
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8566
Mailing Address - Country:US
Mailing Address - Phone:551-996-1140
Mailing Address - Fax:551-996-0543
Practice Address - Street 1:360 ESSEX ST STE 401
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:551-996-1140
Practice Address - Fax:551-996-0543
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09671600207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0459810Medicaid