Provider Demographics
NPI:1184616567
Name:KIM, YOUNG SUN (OD)
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:SUN
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 1:3183 WILSHIRE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1279
Mailing Address - Country:US
Mailing Address - Phone:213-738-0007
Mailing Address - Fax:213-738-0033
Practice Address - Street 1:3183 WILSHIRE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-1279
Practice Address - Country:US
Practice Address - Phone:213-738-0007
Practice Address - Fax:213-738-0033
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10134T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101340Medicaid
CASD0101340Medicaid
CAOP10134Medicare ID - Type Unspecified