Provider Demographics
NPI:1457328825
Name:KIM, MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
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 1:2027 SAN ELIJO AVE STE 2027
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-1726
Mailing Address - Country:US
Mailing Address - Phone:760-452-2895
Mailing Address - Fax:760-452-2898
Practice Address - Street 1:2027 SAN ELIJO AVE STE 2027
Practice Address - Street 2:
Practice Address - City:CARDIFF
Practice Address - State:CA
Practice Address - Zip Code:92007-1726
Practice Address - Country:US
Practice Address - Phone:760-452-2895
Practice Address - Fax:760-452-2898
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP11566DMedicare UPIN
CAU91013Medicare UPIN
CADM596ZMedicare PIN