Provider Demographics
NPI:1497161319
Name:KIM, SUZANNE (OD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
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 1:32 TILTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3543
Mailing Address - Country:US
Mailing Address - Phone:310-279-6124
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-937-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-11
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2914152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation