Provider Demographics
NPI:1821098096
Name:KIM, WALTER S (OD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:S
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 1:237 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4107
Mailing Address - Country:US
Mailing Address - Phone:323-469-1929
Mailing Address - Fax:323-469-1920
Practice Address - Street 1:237 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4107
Practice Address - Country:US
Practice Address - Phone:323-469-1929
Practice Address - Fax:323-469-1920
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT-6975T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0069750Medicaid
T-70163Medicare UPIN
CASD0069750Medicaid