Basic Information
| Provider Information | |||||||||
| NPI: | 1750766002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29138 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480664152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865410747 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 29138 GRATIOT AVE | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480664152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865410747 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901004923 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.