Provider Demographics
NPI:1467439836
Name:KIM, CAROLYN C (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:C
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203
Mailing Address - Country:US
Mailing Address - Phone:818-956-1010
Mailing Address - Fax:818-543-6083
Practice Address - Street 1:607 N CENTRAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1804
Practice Address - Country:US
Practice Address - Phone:818-956-1010
Practice Address - Fax:818-543-6083
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11404TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75843ZMedicaid
W13790Medicare ID - Type Unspecified
CAZZZ75843ZMedicaid