=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528178928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM KIM O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3245 LAWRENCEVILLE SUWANEE RD STE 108
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-6541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-926-3074
-----------------------------------------------------
Fax | 678-606-1911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3245 LAWRENCEVILLE SUWANEE RD STE 108
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-6541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-926-3074
-----------------------------------------------------
Fax | 678-606-1911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | SA53TA638
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT002317
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------