Provider Demographics
NPI:1649345349
Name:KIM, WANG KI (MD)
Entity type:Individual
Prefix:
First Name:WANG
Middle Name:KI
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:54425 LAKESHORE ROAD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-627-3776
Mailing Address - Fax:716-627-1162
Practice Address - Street 1:100 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:GOWANDA
Practice Address - State:NY
Practice Address - Zip Code:14070
Practice Address - Country:US
Practice Address - Phone:716-532-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12339012084A0401X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY69440206OtherLIONEL R JOHN CONTRACT HE
NY00020290301OtherUNIVERA
NY1505718OtherINDEPENDENT HEALTH
NY5074651OtherBLUE CROSS
NY005074651OtherCOMMUNITY BLUE
NY074651OtherBLUE SHIELD
NY1042076OtherFIDELIS CARE
NY69440206OtherCATTARAUGUS INDIAN RESERV
NY01429390Medicaid
NY69440206OtherLIONEL R JOHN CONTRACT HE
NY005074651OtherCOMMUNITY BLUE