Provider Demographics
NPI:1871992719
Name:KIM, AGNES (OD)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E BLUFF ST APT 6105
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-2368
Mailing Address - Country:US
Mailing Address - Phone:318-775-9834
Mailing Address - Fax:
Practice Address - Street 1:1221 FM 1187 E
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4370
Practice Address - Country:US
Practice Address - Phone:817-782-9972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8558TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist