Provider Demographics
NPI:1548398985
Name:KIM, MINA (OD)
Entity Type:Individual
Prefix:DR
First Name:MINA
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 1:6343 DOUGLASTON PKWY # A
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1533
Mailing Address - Country:US
Mailing Address - Phone:917-880-2763
Mailing Address - Fax:
Practice Address - Street 1:189 MONTAGUE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3610
Practice Address - Country:US
Practice Address - Phone:718-855-2333
Practice Address - Fax:718-855-1227
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV00679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist