Provider Demographics
NPI:1528848074
Name:KIM, CHAN YOON (OD)
Entity type:Individual
Prefix:
First Name:CHAN YOON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:CHAN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3497 LORI LN
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-7302
Mailing Address - Country:US
Mailing Address - Phone:678-469-5347
Mailing Address - Fax:
Practice Address - Street 1:1000 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4180
Practice Address - Country:US
Practice Address - Phone:770-968-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist