Provider Demographics
NPI:1588713119
Name:KIM, MICHELLE H (OD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:H
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 1:833 S WESTERN AVE #2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3376
Mailing Address - Country:US
Mailing Address - Phone:213-248-1001
Mailing Address - Fax:213-384-4527
Practice Address - Street 1:833 S WESTERN AVE #2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-3376
Practice Address - Country:US
Practice Address - Phone:213-384-1001
Practice Address - Fax:213-384-4527
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12591T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0125910Medicaid
CASD0125910Medicaid
CAOP12591Medicare PIN
CAOP12591AMedicare PIN