Provider Demographics
NPI:1265961627
Name:KIM, TERRY (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13505 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:ASPEN HILL
Practice Address - State:MD
Practice Address - Zip Code:20906-2912
Practice Address - Country:US
Practice Address - Phone:301-438-0555
Practice Address - Fax:301-438-0556
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2585152W00000X
VA0618002589152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist