Healthcare Provider Details

I. General information

NPI: 1245009141
Provider Name (Legal Business Name): JEONG SU KIM OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3727 W 6TH ST STE 210
LOS ANGELES CA
90020-5108
US

IV. Provider business mailing address

680 S BERENDO ST APT 416
LOS ANGELES CA
90005-1795
US

V. Phone/Fax

Practice location:
  • Phone: 213-235-2500
  • Fax:
Mailing address:
  • Phone: 425-466-3251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: