Provider Demographics
NPI:1861577744
Name:SIM, NICOLE JAE (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:JAE
Last Name:SIM
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 1:2118 VINE ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1524
Mailing Address - Country:US
Mailing Address - Phone:510-548-3947
Mailing Address - Fax:
Practice Address - Street 1:2118 VINE ST
Practice Address - Street 2:SUITE E
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1524
Practice Address - Country:US
Practice Address - Phone:510-548-3947
Practice Address - Fax:510-548-3501
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11438TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0114380Medicare PIN
CAU88002Medicare UPIN