Provider Demographics
NPI:1679577548
Name:MCKIM, DONALD E (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:MCKIM
Suffix:
Gender:M
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:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-0427
Mailing Address - Country:US
Mailing Address - Phone:641-782-7619
Mailing Address - Fax:641-782-6549
Practice Address - Street 1:1610 W TOWNLINE ST
Practice Address - Street 2:STE 115
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1064
Practice Address - Country:US
Practice Address - Phone:641-782-7619
Practice Address - Fax:641-782-6549
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0037465Medicaid
IA01847OtherIOWA LICENSE
IA24565OtherBLUE CROSS BLUE SHIELD
IA01847OtherIOWA LICENSE
IAT65209Medicare UPIN