Provider Demographics
NPI:1942352349
Name:KIM, SUSAN CHAO (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:CHAO
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:TING-TING
Other - Last Name:CHAO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:44414 VALLEY CENTRAL WAY
Mailing Address - Street 2:VALLEY CENTRAL SHOPPING CENTER
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-6528
Mailing Address - Country:US
Mailing Address - Phone:661-723-5381
Mailing Address - Fax:661-723-1335
Practice Address - Street 1:44414 VALLEY CENTRAL WAY
Practice Address - Street 2:VALLEY CENTRAL SHOPPING CENTER
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-6528
Practice Address - Country:US
Practice Address - Phone:661-723-5381
Practice Address - Fax:661-723-1335
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9220T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT30723Medicare UPIN