Provider Demographics
NPI:1669404323
Name:KIM, DAEGYUN (PT, LAC)
Entity type:Individual
Prefix:MR
First Name:DAEGYUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 ROUTE 27 UNIT 3
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-3477
Mailing Address - Country:US
Mailing Address - Phone:732-287-1990
Mailing Address - Fax:
Practice Address - Street 1:1581 ROUTE 27 UNIT 3
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-3477
Practice Address - Country:US
Practice Address - Phone:732-287-1990
Practice Address - Fax:732-287-1996
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00040500171100000X
NY017470225100000X
NJ40QA01140100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02646413Medicaid
NYQ19Y81Medicare PIN