Provider Demographics
NPI:1083737241
Name:KIM, SUMI (OD)
Entity Type:Individual
Prefix:
First Name:SUMI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUMI
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1412 BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1031
Mailing Address - Country:US
Mailing Address - Phone:630-627-3001
Mailing Address - Fax:630-627-3021
Practice Address - Street 1:1412 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1031
Practice Address - Country:US
Practice Address - Phone:630-627-3001
Practice Address - Fax:630-627-3021
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU79891Medicare UPIN
5134810001Medicare ID - Type Unspecified