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General NPI Number Information
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NPI Number | 1164546313
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Entity Type | Individual
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Provider Name | MICHAEL SUKKYU KIM O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 07/27/2021
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Provider Practice Location Address
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Address Line | 134 GRAPEVINE RD
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City | VISTA
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State | CA
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Zip | 92083-4004
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Country | US
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Telephone | 796-631-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 1000 VALE TERRACE DR
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City | VISTA
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State | CA
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Zip | 92084-5218
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Country | US
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Telephone | 760-631-5000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 286
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License Number State | AK
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | DA2093
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License Number State | MD
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Taxonomy #3
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0618001782
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License Number State | VA
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 12174
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License Number State | CA
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