Provider Demographics
NPI:1568581536
Name:KIM, MARY M (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
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 1:978 MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:S. WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190
Mailing Address - Country:US
Mailing Address - Phone:781-337-0674
Mailing Address - Fax:781-331-9106
Practice Address - Street 1:978 MAIN ST.
Practice Address - Street 2:
Practice Address - City:S. WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190
Practice Address - Country:US
Practice Address - Phone:781-337-0674
Practice Address - Fax:781-331-9106
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA455258Medicare ID - Type Unspecified