Provider Demographics
NPI:1124805684
Name:KIM, ETHAN YOOSEOK (OD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:YOOSEOK
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 220TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3647
Mailing Address - Country:US
Mailing Address - Phone:929-369-7211
Mailing Address - Fax:
Practice Address - Street 1:3925 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2060
Practice Address - Country:US
Practice Address - Phone:718-279-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRT009892152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist