1487633228 NPI number — DR. MARK Y KIM D.O.

Table of content: DR. MARK Y KIM D.O. (NPI 1487633228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487633228 NPI number — DR. MARK Y KIM D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
MARK
Provider Middle Name:
Y
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487633228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 ESSJAY RD STE 170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-8235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-630-1219
Provider Business Mailing Address Fax Number:
716-817-1726

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 N BUFFALO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-1842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-656-4804
Provider Business Practice Location Address Fax Number:
716-250-5933
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  234385-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0412847 . This is a "IHA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00027258001 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02680335 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000528214001 . This is a "HEALTH NOW" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 161000580 . This is a "EMPIRE PLAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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