Healthcare Provider Details

I. General information

NPI: 1699953695
Provider Name (Legal Business Name): SALLY I. KIM, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5972 BEACH BLVD
BUENA PARK CA
90621-2024
US

IV. Provider business mailing address

5972 BEACH BLVD
BUENA PARK CA
90621-2024
US

V. Phone/Fax

Practice location:
  • Phone: 714-562-5857
  • Fax: 714-562-8717
Mailing address:
  • Phone: 714-562-5857
  • Fax: 714-562-8717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG57460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: SALLY INJA KIM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-562-5857