Provider Demographics
NPI:1962579045
Name:KIM, SUNG-DONG (DC LAC CA)
Entity type:Individual
Prefix:MR
First Name:SUNG-DONG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:DC LAC CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CHARLOTTE PL
Mailing Address - Street 2:#101
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632
Mailing Address - Country:US
Mailing Address - Phone:201-227-8636
Mailing Address - Fax:201-227-8639
Practice Address - Street 1:111 CHARLOTTE PL
Practice Address - Street 2:#101
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632
Practice Address - Country:US
Practice Address - Phone:201-227-8636
Practice Address - Fax:201-227-8639
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00568000111N00000X
NYX98111111N00000X
NJ25MZ00042300171100000X
NY002988-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1036944OtherASH CHIROPRACTIC
NJ673435OtherACN
NJ9388280OtherPHCS
NJ1065217OtherASH ACUPUNCTURE
U92418Medicare UPIN
NJ1065217OtherASH ACUPUNCTURE