Provider Demographics
NPI:1689648875
Name:KIM, ALYSSA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6262 E BROADWAY RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6101
Mailing Address - Country:US
Mailing Address - Phone:480-898-3937
Mailing Address - Fax:480-924-3945
Practice Address - Street 1:6262 E BROADWAY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6101
Practice Address - Country:US
Practice Address - Phone:480-898-3937
Practice Address - Fax:480-924-3945
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31119207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H66858Medicare UPIN
74301Medicare ID - Type Unspecified