Provider Demographics
NPI:1679808356
Name:KIM, JACK SON (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:SON
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:6495 SAIPAN ST
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5620
Mailing Address - Country:US
Mailing Address - Phone:626-388-7391
Mailing Address - Fax:
Practice Address - Street 1:5832 BEACH BLVD UNIT 109
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-5500
Practice Address - Country:US
Practice Address - Phone:714-228-1888
Practice Address - Fax:714-676-8308
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA13848152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADD503ZMedicare PIN