Provider Demographics
NPI:1710905898
Name:KIM, MI SOON (OD)
Entity Type:Individual
Prefix:MRS
First Name:MI SOON
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 1:4725 1ST ST STE 270
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7136
Mailing Address - Country:US
Mailing Address - Phone:925-249-9642
Mailing Address - Fax:925-249-9643
Practice Address - Street 1:4725 1ST ST STE 270
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-7136
Practice Address - Country:US
Practice Address - Phone:925-249-9642
Practice Address - Fax:925-249-9643
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist