Provider Demographics
NPI:1760832984
Name:KIM, ANDERSON (OD)
Entity Type:Individual
Prefix:
First Name:ANDERSON
Middle Name:
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 1:16 CORDELIA CT
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-8436
Mailing Address - Country:US
Mailing Address - Phone:562-754-1721
Mailing Address - Fax:
Practice Address - Street 1:30 MALL DR W STE 100
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1647
Practice Address - Country:US
Practice Address - Phone:201-798-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-18
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008417-1152W00000X
NY008417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist