Provider Demographics
NPI:1932497161
Name:KIM, SHELLY Z (OD)
Entity Type:Individual
Prefix:DR
First Name:SHELLY
Middle Name:Z
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 W HALF DAY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6555
Mailing Address - Country:US
Mailing Address - Phone:847-913-5545
Mailing Address - Fax:
Practice Address - Street 1:464 W HALF DAY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6555
Practice Address - Country:US
Practice Address - Phone:847-913-5545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211019OtherMEDICARE
IL046010494Medicaid
IL210209OtherMEDICARE
IL8825444OtherMULTIPLAN
IL7235044OtherAETNA
IL1636706OtherBLUECROSS BLUESHIELD OF ILLINOIS
IL502720049OtherMEDICARE PTAN