Provider Demographics
NPI:1003860255
Name:YIM, KA-EUL KELLY (OD)
Entity Type:Individual
Prefix:DR
First Name:KA-EUL
Middle Name:KELLY
Last Name:YIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1412
Mailing Address - Country:US
Mailing Address - Phone:215-635-4787
Mailing Address - Fax:215-758-2628
Practice Address - Street 1:47 CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:CHELTENHAM
Practice Address - State:PA
Practice Address - Zip Code:19012-1412
Practice Address - Country:US
Practice Address - Phone:215-635-4787
Practice Address - Fax:215-758-2628
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1745507OtherPA BLUE SHIELD
PAV08137Medicare UPIN
PA097874TEEMedicare ID - Type UnspecifiedMEDICARE