Provider Demographics
NPI:1376664748
Name:KIM, JOO HAN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOO
Middle Name:HAN
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 1:5866 POST CORNERS TRL APT B
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-6332
Mailing Address - Country:US
Mailing Address - Phone:703-349-0984
Mailing Address - Fax:
Practice Address - Street 1:14000 WORTH AVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4121
Practice Address - Country:US
Practice Address - Phone:703-497-2777
Practice Address - Fax:703-491-0531
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001515152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist