Provider Demographics
NPI:1154331957
Name:KWONG, MIMI SHEN
Entity Type:Individual
Prefix:MRS
First Name:MIMI
Middle Name:SHEN
Last Name:KWONG
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MIMI
Other - Middle Name:YA-PING
Other - Last Name:SHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5289 YORKTON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-2200
Mailing Address - Country:US
Mailing Address - Phone:408-866-4260
Mailing Address - Fax:408-866-4260
Practice Address - Street 1:3801 MIRANDA AVE
Practice Address - Street 2:PALO ALTO VAHCS/WBRC, MAIL STOP #124
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1207
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:650-496-2529
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11824T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU89352Medicare UPIN
CASD0118240Medicare ID - Type Unspecified