Provider Demographics
NPI:1992297493
Name:PANDIANGAN, KIMBERLY (OD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:PANDIANGAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:PANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:6923 COAL CREEK PKWY SE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98059-3136
Mailing Address - Country:US
Mailing Address - Phone:425-641-2500
Mailing Address - Fax:
Practice Address - Street 1:6923 COAL CREEK PKWY SE
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:WA
Practice Address - Zip Code:98059-3136
Practice Address - Country:US
Practice Address - Phone:425-641-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD.OD.60861434152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist