Provider Demographics
NPI:1679808356
Name:KIM, JACK SON (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:SON
Last Name:KIM
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 1:63 W ANGELA ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7328
Mailing Address - Country:US
Mailing Address - Phone:626-388-7391
Mailing Address - Fax:
Practice Address - Street 1:63 W ANGELA ST
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-7328
Practice Address - Country:US
Practice Address - Phone:925-456-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADD503ZMedicare PIN