Provider Demographics
NPI:1992267173
Name:KIM, BRANDON HOONGYUNG
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:HOONGYUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11560-2151
Mailing Address - Country:US
Mailing Address - Phone:631-271-1640
Mailing Address - Fax:
Practice Address - Street 1:480 FOREST AVE
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-2151
Practice Address - Country:US
Practice Address - Phone:631-271-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY331687207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program