Provider Demographics
NPI:1669799698
Name:KIM, PAMELA SUE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:STONY BROOK MEDICINE
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-2040
Mailing Address - Fax:631-444-6031
Practice Address - Street 1:STONY BROOK MEDICINE
Practice Address - Street 2:101 NICOLLS ROAD, HSC T19-090
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-2040
Practice Address - Fax:631-444-6031
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY280575208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery