Provider Demographics
NPI:1376178327
Name:KIM, CHRIS Y (DO)
Entity Type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4756 WINDING CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-3436
Mailing Address - Country:US
Mailing Address - Phone:707-292-5652
Mailing Address - Fax:
Practice Address - Street 1:208 VINTAGE WAY STE K21
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5016
Practice Address - Country:US
Practice Address - Phone:415-897-3377
Practice Address - Fax:415-897-5722
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASLD1717156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician