Provider Demographics
NPI:1194718114
Name:KIM, JUSTIN M (OD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:130 NORRIS LN
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2893
Mailing Address - Country:US
Mailing Address - Phone:830-249-3898
Mailing Address - Fax:830-249-9228
Practice Address - Street 1:130 NORRIS LN
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2893
Practice Address - Country:US
Practice Address - Phone:830-249-3898
Practice Address - Fax:830-249-9228
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6310T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist