MEDICARE: BYUNGHO KIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	237277	CA

General Provider Information

NPI Number	:	1346022787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BYUNGHO KIM

Provider Business Mailing Address
First Line	:	4633 CONVOY ST STE 105
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2319
Country	:	US
Telephone Number	:	858-737-4818
Fax Number	:

Provider Business Practice Location Address
First Line	:	4633 CONVOY ST STE 105
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2319
Country	:	US
Telephone Number	:	858-737-4818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	10/19/2023

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Directions to “ BYUNGHO KIM ” Practice Location

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