Provider Demographics
NPI:1639465701
Name:KIM, DEBBIE (OD)
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:DEBBIE
Other - Middle Name:J
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1302 RINDGE LN # B
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12100 WILSHIRE BLVD STE 1275
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7143
Practice Address - Country:US
Practice Address - Phone:800-485-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13838152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist