Provider Demographics
NPI:1720115850
Name:KIM, HETTY YI (OD)
Entity Type:Individual
Prefix:DR
First Name:HETTY
Middle Name:YI
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 1:14914 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2113
Mailing Address - Country:US
Mailing Address - Phone:818-787-2020
Mailing Address - Fax:818-787-8652
Practice Address - Street 1:14914 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2113
Practice Address - Country:US
Practice Address - Phone:818-787-2020
Practice Address - Fax:818-787-8652
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12390T152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT12390TOtherOPTOM LICENSE