Provider Demographics
NPI:1669560041
Name:KIM, VIVIAN Y (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 25097
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729
Mailing Address - Country:US
Mailing Address - Phone:559-702-1212
Mailing Address - Fax:209-546-6064
Practice Address - Street 1:7145 N CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0359
Practice Address - Country:US
Practice Address - Phone:559-702-1212
Practice Address - Fax:209-546-6064
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65668207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A656680OtherMEDICARE PTAN
CA00A656680OtherMEDICARE PTAN
CA00A656680Medicare ID - Type UnspecifiedMCARE GRP #