Provider Demographics
NPI:1083764682
Name:KIM, JANET SUN-KYOUNG (OD)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:SUN-KYOUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:
Other - Last Name:MASTICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11921 WEATHERBY RD
Mailing Address - Street 2:
Mailing Address - City:ROSSMOOR
Mailing Address - State:CA
Mailing Address - Zip Code:90720-4336
Mailing Address - Country:US
Mailing Address - Phone:562-596-3930
Mailing Address - Fax:
Practice Address - Street 1:3525 W CARSON ST
Practice Address - Street 2:DEL AMO FASHION CENTER UNIT #30
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5704
Practice Address - Country:US
Practice Address - Phone:310-370-2626
Practice Address - Fax:310-370-1850
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11673152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU88021Medicare UPIN
CAWOP11673Medicare ID - Type Unspecified