Provider Demographics
NPI:1861516478
Name:KIM, HENRI DONG-HA (OD)
Entity type:Individual
Prefix:DR
First Name:HENRI
Middle Name:DONG-HA
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 1:34 MANOR DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4144
Mailing Address - Country:US
Mailing Address - Phone:510-435-3462
Mailing Address - Fax:
Practice Address - Street 1:1919 DAVIS ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1208
Practice Address - Country:US
Practice Address - Phone:510-430-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11903TLG152W00000X
CA11903T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU93680Medicare UPIN