Provider Demographics
NPI:1821355587
Name:KIM, ALLEN JI (OD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:JI
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 1:3978 N WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1445
Mailing Address - Country:US
Mailing Address - Phone:503-493-7070
Mailing Address - Fax:
Practice Address - Street 1:3978 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1445
Practice Address - Country:US
Practice Address - Phone:503-493-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3509ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist