Provider Demographics
NPI:1992974653
Name:KIM, SANDY (OD)
Entity type:Individual
Prefix:DR
First Name:SANDY
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 1:1920 ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1544
Mailing Address - Country:US
Mailing Address - Phone:818-720-1548
Mailing Address - Fax:213-381-7447
Practice Address - Street 1:1920 ORCHARD LN
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1544
Practice Address - Country:US
Practice Address - Phone:818-720-1548
Practice Address - Fax:213-381-7447
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10821T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist