Provider Demographics
NPI:1114908605
Name:BAHL, KIM DU (OD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:DU
Last Name:BAHL
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:AMBULATORY CARE CLINIC
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-5512
Practice Address - Fax:214-590-5491
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6541T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00298349OtherRAILROAD MEDICARE
TX175625602Medicaid
TX81657QOtherBLUE CROSS BLUE SHIELD
TX81657QOtherBLUE CROSS BLUE SHIELD
P00298349OtherRAILROAD MEDICARE