Provider Demographics
NPI:1346892361
Name:KIM, DARLENE (OD)
Entity Type:Individual
Prefix:
First Name:DARLENE
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 1:735 JOHN R RD STE 150
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5859
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:
Practice Address - Street 1:1961 S TELEGRAPH RD STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48302-0246
Practice Address - Country:US
Practice Address - Phone:248-972-2555
Practice Address - Fax:248-972-2585
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005379152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1346892361Medicaid