Provider Demographics
NPI:1326249210
Name:IKEMOTO, KIM I (OD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:I
Last Name:IKEMOTO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:I
Other - Last Name:MATSUBARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:9400 ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-2246
Mailing Address - Country:US
Mailing Address - Phone:562-461-3000
Mailing Address - Fax:
Practice Address - Street 1:25825 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3518
Practice Address - Country:US
Practice Address - Phone:310-325-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11923T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist