Provider Demographics
NPI:1003870643
Name:KIM, GRACE ZA (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ZA
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 TAYLOR STATION RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4400
Mailing Address - Country:US
Mailing Address - Phone:614-861-0448
Mailing Address - Fax:614-861-7717
Practice Address - Street 1:245 TAYLOR STATION RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4400
Practice Address - Country:US
Practice Address - Phone:614-861-0448
Practice Address - Fax:614-861-7717
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35038852K207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0333099Medicaid
310909670Medicare ID - Type Unspecified
OH0333099Medicaid