Provider Demographics
NPI:1326220740
Name:KIM, VANESSA (OD)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:KIM
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 1:404 LORELEI ROCK ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-3016
Mailing Address - Country:US
Mailing Address - Phone:702-839-2202
Mailing Address - Fax:
Practice Address - Street 1:8060 W TROPICAL PKWY STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4528
Practice Address - Country:US
Practice Address - Phone:702-839-2202
Practice Address - Fax:702-839-2608
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAR032ZMedicare PIN