Provider Demographics
NPI:1306832936
Name:KIM, GINA E (OD)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:E
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 1:2855 GRAMERCY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1756
Mailing Address - Country:US
Mailing Address - Phone:713-668-6828
Mailing Address - Fax:713-558-8785
Practice Address - Street 1:1229 CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-6401
Practice Address - Country:US
Practice Address - Phone:713-467-6600
Practice Address - Fax:713-467-7914
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5253T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104405902Medicaid
U63893Medicare UPIN
TX8A2093Medicare PIN