Provider Demographics
NPI:1114802659
Name:KIM, YOUNG S
Entity type:Individual
Prefix:
First Name:YOUNG
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4619 CONVOY ST # A6
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-2318
Mailing Address - Country:US
Mailing Address - Phone:858-880-8945
Mailing Address - Fax:
Practice Address - Street 1:4619 CONVOY ST # A6
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2318
Practice Address - Country:US
Practice Address - Phone:858-880-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDO70566332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier