Provider Demographics
NPI:1679689863
Name:KIM, EMILY (OD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
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 1:2800 PLAZA DEL AMO
Mailing Address - Street 2:112
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7388
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 PLAZA DEL AMO
Practice Address - Street 2:112
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-7388
Practice Address - Country:US
Practice Address - Phone:310-533-8539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10701T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0107010Medicaid
CAU78098Medicare UPIN
CASD0107010Medicaid