Provider Demographics
NPI:1417007915
Name:KIM, MIAE CHUNG (OD)
Entity Type:Individual
Prefix:DR
First Name:MIAE
Middle Name:CHUNG
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 1:1021 S WOLFE RD
Mailing Address - Street 2:STE 145
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-8880
Mailing Address - Country:US
Mailing Address - Phone:408-737-2020
Mailing Address - Fax:
Practice Address - Street 1:1296 KIFER RD STE 602
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-5318
Practice Address - Country:US
Practice Address - Phone:408-737-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12312152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGI843ZMedicare PIN
CAU98174Medicare UPIN