Provider Demographics
NPI:1073800686
Name:KIM, CONNIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:KIM
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 1:27 SOUTHLAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-1838
Mailing Address - Country:US
Mailing Address - Phone:408-603-4206
Mailing Address - Fax:
Practice Address - Street 1:6898 RALEIGH RD.
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119
Practice Address - Country:US
Practice Address - Phone:408-908-7944
Practice Address - Fax:408-908-7945
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-03
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14347TLG152WV0400X
CAOPT14347-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy