Provider Demographics
NPI:1841711082
Name:KIM, JANE (OD)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
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 1:1404 INDIAN SPGS
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 MELBOURNE RD STE 3002
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-6225
Practice Address - Country:US
Practice Address - Phone:817-284-0798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9172T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty