Provider Demographics
NPI:1073946406
Name:KIM, TAE WON (OD)
Entity Type:Individual
Prefix:DR
First Name:TAE WON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S W S YOUNG DR STE A
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-5352
Mailing Address - Country:US
Mailing Address - Phone:254-953-1164
Mailing Address - Fax:
Practice Address - Street 1:2100 S W S YOUNG DR STE 1000
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5355
Practice Address - Country:US
Practice Address - Phone:254-261-7449
Practice Address - Fax:254-261-7450
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4831152W00000X
TX9128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist