Provider Demographics
NPI:1467978684
Name:TA, KIM THIEN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:THIEN
Last Name:TA
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 1:913 SYDNEY ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-6225
Mailing Address - Country:US
Mailing Address - Phone:337-255-4412
Mailing Address - Fax:
Practice Address - Street 1:1633 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-2897
Practice Address - Country:US
Practice Address - Phone:985-851-6373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1860-794AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist