MEDICARE: SALLY I. KIM, M.D., INC.

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	332H00000X	Eyewear Supplier
2	207W00000X	Ophthalmology Physician	G57460	CA

General Provider Information

NPI Number	:	1699953695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALLY I. KIM, M.D., INC.

Provider Business Mailing Address
First Line	:	5972 BEACH BLVD
Second Line	:
City	:	BUENA PARK
State	:	CA
Zip	:	90621-2024
Country	:	US
Telephone Number	:	714-562-5857
Fax Number	:	714-562-8717

Provider Business Practice Location Address
First Line	:	5972 BEACH BLVD
Second Line	:
City	:	BUENA PARK
State	:	CA
Zip	:	90621-2024
Country	:	US
Telephone Number	:	714-562-5857
Fax Number	:	714-562-8717

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SALLY INJA KIM
Credential	:	M.D.
Telephone Number	:	714-562-5857

Provider Enumeration Date	:	02/01/2008
Last Update Date	:	06/08/2020

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