Provider Demographics
NPI:1922307628
Name:CHENG, KIMBERLY (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:CHENG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:34 DORCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 FOREST AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1469
Practice Address - Country:US
Practice Address - Phone:408-295-3433
Practice Address - Fax:408-293-4872
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGP321ZMedicare PIN