Healthcare Provider Details

I. General information

NPI: 1629418983
Provider Name (Legal Business Name): KYUNG EUN MIN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE MIN

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E COLORADO BLVD
PASADENA CA
91101-2024
US

IV. Provider business mailing address

477 E COLORADO BLVD
PASADENA CA
91101-2024
US

V. Phone/Fax

Practice location:
  • Phone: 626-796-1191
  • Fax:
Mailing address:
  • Phone: 626-796-1191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00647400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33588TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: