Provider Demographics
NPI:1497778393
Name:KIM, MIRAN JULIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MIRAN
Middle Name:JULIE
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 1:2125 E THOUSAND OAKS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2945
Mailing Address - Country:US
Mailing Address - Phone:805-557-1055
Mailing Address - Fax:805-557-1101
Practice Address - Street 1:2125 E THOUSAND OAKS BLVD STE A
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2945
Practice Address - Country:US
Practice Address - Phone:805-557-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10702T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU66086Medicare UPIN