Provider Demographics
NPI:1972660439
Name:KIM, YOUNG C (OD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:C
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:250 FORTUNE BLVD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1743
Mailing Address - Country:US
Mailing Address - Phone:508-473-1042
Mailing Address - Fax:508-473-1058
Practice Address - Street 1:250 FORTUNE BLVD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1743
Practice Address - Country:US
Practice Address - Phone:508-478-5604
Practice Address - Fax:508-478-5639
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0317730Medicaid
U77974Medicare UPIN
MA0317730Medicaid