1063537397 NPI number — AGNES (YANG EUN) PYONG KIM O.D.

Table of content: AGNES (YANG EUN) PYONG KIM O.D. (NPI 1063537397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063537397 NPI number — AGNES (YANG EUN) PYONG KIM O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIM
Provider First Name:
AGNES (YANG EUN)
Provider Middle Name:
PYONG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIM
Provider Other First Name:
YANG EUN
Provider Other Middle Name:
PYONG
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063537397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6084 RALSTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94805-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-215-2329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 ARNOLD DR
Provider Second Line Business Practice Location Address:
LOCATED INSIDE WAL-MART
Provider Business Practice Location Address City Name:
MARTINEZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94553-4103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-957-9378
Provider Business Practice Location Address Fax Number:
925-957-9417
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  12313T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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