Provider Demographics
NPI:1033208095
Name:KIM, GRACE M (OD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:600 FIRESTONE DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20905-8006
Mailing Address - Country:US
Mailing Address - Phone:240-426-2208
Mailing Address - Fax:
Practice Address - Street 1:513 BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014
Practice Address - Country:US
Practice Address - Phone:410-836-0098
Practice Address - Fax:410-836-0104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist