Provider Demographics
NPI:1215525829
Name:KIM, MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
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 1:12640 MAGNA CARTA RD
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2709
Mailing Address - Country:US
Mailing Address - Phone:703-579-7019
Mailing Address - Fax:
Practice Address - Street 1:42015 VILLAGE CENTER PLZ STE 103
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105-3031
Practice Address - Country:US
Practice Address - Phone:703-542-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist