Provider Demographics
NPI:1053646133
Name:SO, KELVIN KIU WING (OD)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:KIU WING
Last Name:SO
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 1:2543 NW OVERLOOK DR APT 127
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7606
Mailing Address - Country:US
Mailing Address - Phone:503-880-1381
Mailing Address - Fax:
Practice Address - Street 1:2043 COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1756
Practice Address - Country:US
Practice Address - Phone:503-880-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3414ATI152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist