Provider Demographics
NPI:1497807838
Name:KIM, JANETTE J (OD)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:J
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 1:18527 CALLE VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1927
Mailing Address - Country:US
Mailing Address - Phone:818-368-0192
Mailing Address - Fax:
Practice Address - Street 1:317 N LARCHMONT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3011
Practice Address - Country:US
Practice Address - Phone:323-465-9682
Practice Address - Fax:323-467-4043
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV05890Medicare UPIN