Provider Demographics
NPI:1083639181
Name:KIM, CHANG H (OD)
Entity Type:Individual
Prefix:DR
First Name:CHANG
Middle Name:H
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 1:351 E TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3328
Mailing Address - Country:US
Mailing Address - Phone:213-253-2677
Mailing Address - Fax:
Practice Address - Street 1:351 E TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3328
Practice Address - Country:US
Practice Address - Phone:213-253-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9483T152W00000X
TN2223152W00000X
WA3236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist