Provider Demographics
NPI:1164546313
Name:KIM, MICHAEL SUKKYU (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SUKKYU
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 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:
Practice Address - Street 1:134 GRAPEVINE RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-4004
Practice Address - Country:US
Practice Address - Phone:796-631-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK286152W00000X
MDDA2093174400000X
VA0618001782174400000X
CA12174152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU99095Medicare UPIN