Provider Demographics
NPI:1265510739
Name:KIM, DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
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 1:1130 LAKE PLAZA DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3594
Mailing Address - Country:US
Mailing Address - Phone:719-219-3819
Mailing Address - Fax:719-219-0411
Practice Address - Street 1:1130 LAKE PLAZA DR
Practice Address - Street 2:SUITE 230
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3594
Practice Address - Country:US
Practice Address - Phone:719-219-3819
Practice Address - Fax:719-219-0411
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA12426T152W00000X
CO2784152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79138276Medicaid
CO79138276Medicaid