Provider Demographics
NPI:1912216987
Name:PHAN, KIMBERLY SUE (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:PHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 MAIN ST APT 2059
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-3200
Mailing Address - Country:US
Mailing Address - Phone:951-522-1370
Mailing Address - Fax:
Practice Address - Street 1:13662A JAMBOREE RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-1201
Practice Address - Country:US
Practice Address - Phone:714-508-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist