Healthcare Provider Details

I. General information

NPI: 1649182239
Provider Name (Legal Business Name): SEONGEUN KIM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 BELLEVUE AVE
MONTCLAIR NJ
07043-1885
US

IV. Provider business mailing address

211 BELLEVUE AVE
MONTCLAIR NJ
07043-1885
US

V. Phone/Fax

Practice location:
  • Phone: 973-707-5255
  • Fax:
Mailing address:
  • Phone: 973-707-5255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number27OA00745900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: