Provider Demographics
NPI:1629381512
Name:KIM, MARISA MAYUMI (OD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:MAYUMI
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 1:1380 LUSITANA ST STE 604
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2442
Mailing Address - Country:US
Mailing Address - Phone:808-523-2020
Mailing Address - Fax:
Practice Address - Street 1:1380 LUSITANA ST STE 604
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2442
Practice Address - Country:US
Practice Address - Phone:808-523-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13998152W00000X
HI724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74327755Medicaid
NM8HN855Medicare PIN