Provider Demographics
NPI:1033257894
Name:YIM, IRENE IIKYUNG (OD)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:IIKYUNG
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 1:18337 COLIMA RD
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2762
Mailing Address - Country:US
Mailing Address - Phone:626-854-1131
Mailing Address - Fax:626-854-1727
Practice Address - Street 1:18337 COLIMA RD
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2762
Practice Address - Country:US
Practice Address - Phone:626-854-1131
Practice Address - Fax:626-854-1727
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9722T152W00000X, 152WC0802X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0097220Medicaid
CASD0097220Medicaid