Provider Demographics
NPI:1760648497
Name:KIM, GRACE J (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2285 E KEN PRATT BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5223
Mailing Address - Country:US
Mailing Address - Phone:720-652-0455
Mailing Address - Fax:303-532-3269
Practice Address - Street 1:2285 E KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5223
Practice Address - Country:US
Practice Address - Phone:720-652-0455
Practice Address - Fax:303-532-3269
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00614700152W00000X
NYTUV007342152W00000X
CO0003344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ27OA00614700OtherDOCTOR OF OPTOMETRY
NJ27OM00066800OtherORAL MEDICATION LICENSE