Provider Demographics
NPI:1235280280
Name:VILLEGAN, KIMERLY BETH (OD)
Entity Type:Individual
Prefix:
First Name:KIMERLY
Middle Name:BETH
Last Name:VILLEGAN
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 1:5J SERRAMONTE CTR
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2345
Mailing Address - Country:US
Mailing Address - Phone:650-992-1615
Mailing Address - Fax:650-992-1617
Practice Address - Street 1:925 BLOSSOM HILL RD
Practice Address - Street 2:OAKRIDGE MALL #1451
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-1230
Practice Address - Country:US
Practice Address - Phone:408-284-0140
Practice Address - Fax:408-448-2130
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 7378T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10523Medicare UPIN
CASDO073780Medicare ID - Type Unspecified