Provider Demographics
NPI:1053717629
Name:KIM, SOOJI (DPM)
Entity type:Individual
Prefix:
First Name:SOOJI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-2620
Mailing Address - Country:US
Mailing Address - Phone:845-642-8851
Mailing Address - Fax:
Practice Address - Street 1:233 BROADWAY RM 1775
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10279-1810
Practice Address - Country:US
Practice Address - Phone:212-921-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006777213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04524594Medicaid
NY006777OtherLICENSE