MEDICARE: INDIANA RETINA CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207WX0107X	Retina Specialist (Ophthalmology) Physician

General Provider Information

NPI Number	:	1518609429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA RETINA CENTER LLC

Provider Business Mailing Address
First Line	:	7802 W JEFFERSON BLVD STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4138
Country	:	US
Telephone Number	:	260-305-2822
Fax Number	:

Provider Business Practice Location Address
First Line	:	7802 W JEFFERSON BLVD STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4138
Country	:	US
Telephone Number	:	260-305-2822
Fax Number	:	260-305-2829

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JAMES DAEOK KIM
Credential	:	MD
Telephone Number	:	260-305-2822

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	03/03/2026

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