Provider Demographics
NPI:1538777255
Name:KIM, JAMES BONG-SUK (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BONG-SUK
Last Name:KIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19747 W 12 MILE RD STE L7A
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2584
Mailing Address - Country:US
Mailing Address - Phone:754-304-1065
Mailing Address - Fax:
Practice Address - Street 1:19747 W 12 MILE RD STE L7A
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2584
Practice Address - Country:US
Practice Address - Phone:754-304-1065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist