{
"Npi": {
"NPI": "1679808356",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "KIM",
"FirstName": "JACK",
"MiddleName": "SON",
"NamePrefix": "DR.",
"NameSuffix": null,
"Credential": "O.D.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "6495 SAIPAN ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CYPRESS",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "90630-5620",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "626-388-7391",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "5832 BEACH BLVD UNIT 109",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "BUENA PARK",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "90621-5500",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "714-228-1888",
"PracticeLocationAddressFaxNumber": "714-676-8308",
"EnumerationDate": "10/13/2009",
"LastUpdateDate": "01/09/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "13848",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}